Provider Demographics
NPI:1558542092
Name:CROUSE, MAKENZI (PA)
Entity Type:Individual
Prefix:
First Name:MAKENZI
Middle Name:
Last Name:CROUSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MAKENZI
Other - Middle Name:
Other - Last Name:GILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:14601 HOPE CENTER LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4707
Mailing Address - Country:US
Mailing Address - Phone:239-334-7000
Mailing Address - Fax:239-334-7070
Practice Address - Street 1:14601 HOPE CENTER LOOP
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4707
Practice Address - Country:US
Practice Address - Phone:239-334-7000
Practice Address - Fax:239-334-7070
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104421363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00746161OtherRR MEDICARE
FL292951100Medicaid
FLPA9104421OtherSTATE LICENSE
FL3894080001Medicare NSC
FLPA9104421OtherSTATE LICENSE