MEDICARE: MR. KERRY LEE MCKENZIE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	166	WY

General Provider Information

NPI Number	:	1619093879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KERRY LEE MCKENZIE PA-C

Provider Business Mailing Address
First Line	:	1208 HILLTOP DR
Second Line	:	SUITE 100
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5857
Country	:	US
Telephone Number	:	307-352-8199
Fax Number	:	307-352-8148

Provider Business Practice Location Address
First Line	:	1204 HILLTOP DR
Second Line	:	SUITE 108
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5861
Country	:	US
Telephone Number	:	307-352-8125
Fax Number	:	307-352-8126

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	08/24/2012

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