Healthcare Provider Details

I. General information

NPI: 1740910793
Provider Name (Legal Business Name): MACKENZIE CUMMINGS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MEDICAL CENTER DR STE 300
MEDFORD OR
97504-4316
US

IV. Provider business mailing address

520 MEDICAL CENTER DR STE 300
MEDFORD OR
97504-4316
US

V. Phone/Fax

Practice location:
  • Phone: 541-930-8907
  • Fax: 541-245-4820
Mailing address:
  • Phone: 541-930-8907
  • Fax: 541-245-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA218550
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA218550
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: