Provider Demographics
NPI:1780216481
Name:KRETZSCHMAR, MACKENZIE RAASCH (PA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAASCH
Last Name:KRETZSCHMAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:DENK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5201
Mailing Address - Fax:
Practice Address - Street 1:710 COMMERCE DR STE 200
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4925
Practice Address - Country:US
Practice Address - Phone:651-968-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13806363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant