Provider Demographics
NPI:1255720355
Name:HUDIBURG, MACKENCI (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MACKENCI
Middle Name:
Last Name:HUDIBURG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 MONTCLAIR DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1764
Mailing Address - Country:US
Mailing Address - Phone:405-488-4173
Mailing Address - Fax:
Practice Address - Street 1:700 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5004
Practice Address - Country:US
Practice Address - Phone:405-271-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant