Healthcare Provider Details

I. General information

NPI: 1235755190
Provider Name (Legal Business Name): MACKENZIE ROSE BETZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W 13TH ST STE 321
JASPER IN
47546-1857
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-996-7918
  • Fax:
Mailing address:
  • Phone: 812-996-8478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002980A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: