Healthcare Provider Details

I. General information

NPI: 1730711417
Provider Name (Legal Business Name): MACKENZIE L EITER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HARVARD ST SE
MINNEAPOLIS MN
55455-0363
US

IV. Provider business mailing address

720 WASHINGTON AVE SE STE 200
MINNEAPOLIS MN
55414-2924
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-8383
  • Fax:
Mailing address:
  • Phone: 612-884-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14485
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: