Provider Demographics
NPI:1881100808
Name:INTLEHOUSE, MACKENZIE COLE (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:COLE
Last Name:INTLEHOUSE
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 1:700 OLYMPIC PLAZA CIR STE 600
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1954
Mailing Address - Country:US
Mailing Address - Phone:903-596-3488
Mailing Address - Fax:
Practice Address - Street 1:700 OLYMPIC PLAZA CIR STE 600
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1954
Practice Address - Country:US
Practice Address - Phone:903-596-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11528363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX379871201Medicaid