Provider Demographics
NPI:1578210837
Name:HUMPHREY, MCKENZIE BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:BETH
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:BETH
Other - Last Name:DUNLAP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7003 DOROTHY LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4909
Mailing Address - Country:US
Mailing Address - Phone:817-412-1242
Mailing Address - Fax:
Practice Address - Street 1:9139 WESTOVER HILLS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-2889
Practice Address - Country:US
Practice Address - Phone:817-412-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant