Provider Demographics
NPI:1255994661
Name:EBELING, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:EBELING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 W BELVEDERE AVE STE 42
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2435 W BELVEDERE AVE STE 42
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-5843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007176363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical