Healthcare Provider Details

I. General information

NPI: 1811562887
Provider Name (Legal Business Name): MACKENZIE ANDRA SHERON BRUCE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2021
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 OAK MANOR LN
LARGO FL
33774-1212
US

IV. Provider business mailing address

PO BOX 734951
CHICAGO IL
60673-4951
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: