=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023747045
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAKENZIE SANGALLI PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2022
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2851 W INTERSTATE HWY 635
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75063-3870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-496-0820
-----------------------------------------------------
Fax | 214-496-0425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2851 W INTERSTATE HWY 635
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75063-3870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-701-3240
-----------------------------------------------------
Fax | 214-496-0425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA15698
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------