Healthcare Provider Details

I. General information

NPI: 1164049201
Provider Name (Legal Business Name): MAKENZIE BISHOP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2020
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W 1325 N STE 200
CEDAR CITY UT
84721-8179
US

IV. Provider business mailing address

110 W 1325 N STE 200
CEDAR CITY UT
84721-8179
US

V. Phone/Fax

Practice location:
  • Phone: 435-586-7676
  • Fax: 435-586-2290
Mailing address:
  • Phone: 435-586-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11917253-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: