Provider Demographics
NPI:1922085265
Name:MCKENZIE, JASON S (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 E PRATER WAY
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-4679
Mailing Address - Country:US
Mailing Address - Phone:775-351-1300
Mailing Address - Fax:775-351-1344
Practice Address - Street 1:480 E PRATER WAY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-4679
Practice Address - Country:US
Practice Address - Phone:775-351-1300
Practice Address - Fax:775-351-1344
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016747Medicaid
G74935Medicare UPIN
NVV32524Medicare PIN