Healthcare Provider Details

I. General information

NPI: 1629422993
Provider Name (Legal Business Name): MACKENZIE M MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 E 28TH ST SUITE 460
MINNEAPOLIS MN
55407-1286
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-7770
  • Fax:
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number66100
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: