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General NPI Number Information
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NPI Number | 1306586698
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Entity Type | Individual
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Provider Name | MACKENZIE MARTIN CRNA
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Gender | Male
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Dates
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Enumeration Date | 04/01/2022
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Last Update Date | 05/16/2022
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Provider Practice Location Address
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Address Line | 425 LEWIS HARGETT CIR
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City | LEXINGTON
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State | KY
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Zip | 40503-3590
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Country | US
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Telephone | 859-268-1030
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Fax |
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Provider Business Mailing Address
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Address Line | 381 ROCKLICK BRANCH RD
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City | CHAPMANVILLE
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State | WV
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Zip | 25508-7651
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Country | US
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Telephone | 304-928-4464
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 93493
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 3017780
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License Number State | KY
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