Provider Demographics
NPI:1598243750
Name:MAHR, MACKENZIE EILEEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:EILEEN
Last Name:MAHR
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 1:1413 KINGHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1742
Mailing Address - Country:US
Mailing Address - Phone:130-121-9227
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant