Provider Demographics
NPI:1972920619
Name:MONAHAN, MACKENZIE RYAN (PA-C, MPAS)
Entity Type:Individual
Prefix:MR
First Name:MACKENZIE
Middle Name:RYAN
Last Name:MONAHAN
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-9000
Mailing Address - Country:US
Mailing Address - Phone:802-674-7300
Mailing Address - Fax:
Practice Address - Street 1:289 COUNTY RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-9000
Practice Address - Country:US
Practice Address - Phone:802-674-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant