=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699098749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK DOUGLAS MCKENZIE RN, BSN, MSN, FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2010
-----------------------------------------------------
Last Update Date | 03/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 NORTHGATE BLVD SUITE 100
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95834-1128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-929-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2114 LIGHTHOUSE DR
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-1853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-426-2239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 296107
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------