Provider Demographics
NPI:1568038875
Name:THEIS, MACKENZIE LEE (PA)
Entity Type:Individual
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First Name:MACKENZIE
Middle Name:LEE
Last Name:THEIS
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Gender:F
Credentials:PA
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Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:952-512-5651
Practice Address - Street 1:6565 FRANCE AVE S STE 200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2141
Practice Address - Country:US
Practice Address - Phone:952-920-2200
Practice Address - Fax:952-920-0866
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
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Provider Licenses
StateLicense IDTaxonomies
MN13706363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant