Provider Demographics
NPI:1982201091
Name:WARNER, MACKENZIE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANN
Last Name:WARNER
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 1:1325 PENNSYLVANIA AVE STE 890
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2145
Mailing Address - Country:US
Mailing Address - Phone:817-250-7247
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 890
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2145
Practice Address - Country:US
Practice Address - Phone:817-250-7247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant