Healthcare Provider Details

I. General information

NPI: 1407479272
Provider Name (Legal Business Name): MACKENZIE MALCOLM GRAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 CAREW ST
SPRINGFIELD MA
01104-2377
US

IV. Provider business mailing address

SURGICAL PA DEPT 271 CAREW ST
SPRINGFIELD MA
01104-2377
US

V. Phone/Fax

Practice location:
  • Phone: 413-748-7353
  • Fax:
Mailing address:
  • Phone: 413-748-7353
  • Fax: 413-748-7357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA7598
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: