Provider Demographics
NPI:1518648104
Name:EISEMAN, MACKENZIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:EISEMAN
Suffix:
Gender:F
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 1:1119 WOODRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-4502
Mailing Address - Country:US
Mailing Address - Phone:615-429-8246
Mailing Address - Fax:
Practice Address - Street 1:110 CONN TER
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3206
Practice Address - Country:US
Practice Address - Phone:615-429-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC392363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant