Provider Demographics
NPI:1437813680
Name:ANDERSON, MACKENZIE RACHEL
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RACHEL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EASTSIDE RD
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-9800
Mailing Address - Country:US
Mailing Address - Phone:608-348-2331
Mailing Address - Fax:
Practice Address - Street 1:1400 EASTSIDE RD
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-9800
Practice Address - Country:US
Practice Address - Phone:608-348-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7219-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant