Provider Demographics
NPI:1891780086
Name:MCKENZIE, NANCY J (PA)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:J
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:KS
Mailing Address - Zip Code:67045-1067
Mailing Address - Country:US
Mailing Address - Phone:620-583-7451
Mailing Address - Fax:620-583-6702
Practice Address - Street 1:110 E 16TH ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:KS
Practice Address - Zip Code:67045-1067
Practice Address - Country:US
Practice Address - Phone:620-583-7451
Practice Address - Fax:620-583-6702
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100352110CMedicaid
178960OtherRURAL HEALTH MEDICARE
100428860AOtherGROUP MEDICAID
100428860AOtherGROUP MEDICAID
R30908Medicare UPIN
KS100352110CMedicaid