MEDICARE: MACKENZIE LYNN MOORE MPAS, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA18351	TX

General Provider Information

NPI Number	:	1578380986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE LYNN MOORE MPAS, PA-C

Provider Business Mailing Address
First Line	:	900 MATISSE DR APT 4028
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2484
Country	:	US
Telephone Number	:	903-348-6341
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 MATISSE DR APT 4028
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2484
Country	:	US
Telephone Number	:	903-348-6341
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2024
Last Update Date	:	09/25/2024

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