Provider Demographics
NPI:1073264008
Name:LOBDELL, MAKENZIE RYAN
Entity type:Individual
Prefix:MR
First Name:MAKENZIE
Middle Name:RYAN
Last Name:LOBDELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR STE 310
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6862
Practice Address - Country:US
Practice Address - Phone:803-434-8323
Practice Address - Fax:803-434-8326
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC29210363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program