Provider Demographics
NPI:1023271632
Name:MCCROREY, MACKENZIE ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANNE
Last Name:MCCROREY
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 1:852 SE 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2001
Mailing Address - Country:US
Mailing Address - Phone:312-925-5903
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST STE 365
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2474
Practice Address - Country:US
Practice Address - Phone:503-261-4430
Practice Address - Fax:503-261-4436
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003524363A00000X, 363AS0400X
ORPA195380363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01216933OtherMEDICARE RAILROAD (PROVIDER PTAN)
IL206147OtherMEDICARE (GROUP PTAN)
IL206147235OtherMEDICARE (INDIVIDUAL)
ILCA4748OtherMEDICARE RAILROAD (GROUP PTAN)