Provider Demographics
NPI:1730720301
Name:WARRICK, MACKENZIE S (PA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:S
Last Name:WARRICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:S
Other - Last Name:REDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:53880 CARMICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1567
Mailing Address - Country:US
Mailing Address - Phone:574-247-9441
Mailing Address - Fax:574-247-9442
Practice Address - Street 1:53880 CARMICHAEL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1567
Practice Address - Country:US
Practice Address - Phone:574-247-9441
Practice Address - Fax:574-247-9442
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10002823AOtherINDIANA MEDICAL LICENSE