Provider Demographics
NPI:1689358780
Name:WALDRAN, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WALDRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20106 SAM IRVIN DR
Mailing Address - Street 2:
Mailing Address - City:TANNER
Mailing Address - State:AL
Mailing Address - Zip Code:35671-3676
Mailing Address - Country:US
Mailing Address - Phone:989-798-7821
Mailing Address - Fax:
Practice Address - Street 1:1716 9TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1124
Practice Address - Country:US
Practice Address - Phone:205-934-5149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant