Provider Demographics
NPI:1407479272
Name:GRAY, MACKENZIE MALCOLM (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MALCOLM
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SURGICAL PA DEPT
Mailing Address - Street 2:271 CAREW ST
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2377
Mailing Address - Country:US
Mailing Address - Phone:413-748-7353
Mailing Address - Fax:413-748-7357
Practice Address - Street 1:271 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2377
Practice Address - Country:US
Practice Address - Phone:413-748-7353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7598363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical