Provider Demographics
NPI:1356744890
Name:MCKENZIE, KENNETH CHANDLER (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CHANDLER
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2705
Mailing Address - Country:US
Mailing Address - Phone:307-672-1161
Mailing Address - Fax:307-672-2791
Practice Address - Street 1:1401 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2705
Practice Address - Country:US
Practice Address - Phone:307-672-1161
Practice Address - Fax:307-672-2791
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA - 1194363A00000X
ORPA176761363A00000X
WYPA728363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY147317400Medicaid