Healthcare Provider Details

I. General information

NPI: 1972250504
Provider Name (Legal Business Name): MACKENZIE JO KEUTZER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MACKENZIE JO LONG PA-C

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 WORNALL RD
KANSAS CITY MO
64111-3241
US

IV. Provider business mailing address

901 E 104TH ST # 3000S
KANSAS CITY MO
64131-4517
US

V. Phone/Fax

Practice location:
  • Phone: 816-932-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2023029157
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: