Provider Demographics
NPI:1619077187
Name:MACKENZIE, JOSEPH R (PA - C)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:PA - C
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:MACKENZIE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1215 22ND AVE.
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:INTERSTATE MEDICAL OFFICE SOUTH
Practice Address - Street 2:3500 N. INTERSTATE AVE.
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-285-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00326363AM0700X
WAPA10001610363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical