Provider Demographics
NPI:1124802525
Name:GAUTHIER, MACKENZIE RAE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 HIGHWAY 457
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302-9293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1409 CHURCH ST
Practice Address - Street 2:
Practice Address - City:JEANERETTE
Practice Address - State:LA
Practice Address - Zip Code:70544-4407
Practice Address - Country:US
Practice Address - Phone:337-276-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant