Provider Demographics
NPI:1194521328
Name:MINNICK, MACKENZIE AUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:AUSTIN
Last Name:MINNICK
Suffix:
Gender:
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 1:1331 S FEDERAL HWY UNIT 207
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-6020
Mailing Address - Country:US
Mailing Address - Phone:512-914-1815
Mailing Address - Fax:
Practice Address - Street 1:3000 BAYVIEW DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1772
Practice Address - Country:US
Practice Address - Phone:954-567-1332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18740363A00000X
FLPA9119867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant