Provider Demographics
NPI:1578059143
Name:HART, MCKENZIE
Entity Type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MCKENZIE
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4334 S ALEUT WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6033
Mailing Address - Country:US
Mailing Address - Phone:208-521-8370
Mailing Address - Fax:
Practice Address - Street 1:4334 S ALEUT WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6033
Practice Address - Country:US
Practice Address - Phone:208-521-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant