Provider Demographics
NPI:1073360277
Name:BONILLA REYES, MACKENZIE BRANNON (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:BRANNON
Last Name:BONILLA REYES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:BRANNON
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:327 HOUSTON ST NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-3258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-446-5185
Practice Address - Fax:704-446-0221
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-04
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-15028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty