Provider Demographics
NPI:1457391195
Name:LEIBOWITZ, MCKENZY DUFFEY (PA)
Entity type:Individual
Prefix:
First Name:MCKENZY
Middle Name:DUFFEY
Last Name:LEIBOWITZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26516 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3970
Mailing Address - Country:US
Mailing Address - Phone:310-541-7911
Mailing Address - Fax:
Practice Address - Street 1:1427 MONTEREY BLVD
Practice Address - Street 2:STE 202
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3639
Practice Address - Country:US
Practice Address - Phone:310-376-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ20988Medicare UPIN
MAQ20988Medicare UPIN