Provider Demographics
NPI:1881643450
Name:LURIE, MACKENZIE R (PA)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:R
Last Name:LURIE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:2000 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-226-6400
Practice Address - Fax:928-226-6410
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-05-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ1058116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ01313Medicare UPIN
AZ107910Medicare PIN