Provider Demographics
NPI:1104581644
Name:MILLER, MAKENZI LANE (PA-C)
Entity type:Individual
Prefix:
First Name:MAKENZI
Middle Name:LANE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 SW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2494
Mailing Address - Country:US
Mailing Address - Phone:405-378-5491
Mailing Address - Fax:405-378-5492
Practice Address - Street 1:1060 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2494
Practice Address - Country:US
Practice Address - Phone:405-378-5491
Practice Address - Fax:405-378-5492
Is Sole Proprietor?:No
Enumeration Date:2021-10-31
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
OK4676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical