Provider Demographics
NPI:1215683255
Name:HILGENBERG, MAKENZIE JANE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MAKENZIE
Middle Name:JANE
Last Name:HILGENBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MAKENZIE
Other - Middle Name:JANE
Other - Last Name:FISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18956 N DALE MABRY HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4915
Mailing Address - Country:US
Mailing Address - Phone:813-948-8597
Mailing Address - Fax:813-949-5919
Practice Address - Street 1:18956 N DALE MABRY HWY STE 102
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4915
Practice Address - Country:US
Practice Address - Phone:813-948-8597
Practice Address - Fax:813-949-5919
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9115635OtherPA-C LICENSE NUMBER