Healthcare Provider Details

I. General information

NPI: 1336075753
Provider Name (Legal Business Name): EVAN MCKENZIE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MCBRIEN RD
EAST RIDGE TN
37412-3223
US

IV. Provider business mailing address

654 MARINER WAY
CHATTANOOGA TN
37402-2924
US

V. Phone/Fax

Practice location:
  • Phone: 423-894-3589
  • Fax:
Mailing address:
  • Phone: 423-991-0316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7103
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: