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General NPI Number Information
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NPI Number | 1073360277
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Entity Type | Individual
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Provider Name | MACKENZIE BRANNON BONILLA REYES PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/04/2024
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Last Update Date | 01/28/2025
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Provider Practice Location Address
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Address Line | 1000 BLYTHE BLVD
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City | CHARLOTTE
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State | NC
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Zip | 28203-5812
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Country | US
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Telephone | 704-446-5185
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Fax | 704-446-0221
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Provider Business Mailing Address
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Address Line | 327 HOUSTON ST NE
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City | CONCORD
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State | NC
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Zip | 28025-3258
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-15028
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License Number State | NC
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