MEDICARE: MACKENZIE T THOMAS AGNP-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	208D00000X	General Practice Physician	NUR-APRN-LIC-289045	MT

General Provider Information

NPI Number	:	1760319925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE T THOMAS AGNP-C

Provider Business Mailing Address
First Line	:	2036 S 13TH ST W
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-4932
Country	:	US
Telephone Number	:	406-241-5370
Fax Number	:

Provider Business Practice Location Address
First Line	:	2230 N RESERVE ST STE 110
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1364
Country	:	US
Telephone Number	:	406-926-5111
Fax Number	:	406-434-6323

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

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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