Provider Demographics
NPI:1306586698
Name:MARTIN, MACKENZIE (CRNA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 ROCKLICK BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-7651
Mailing Address - Country:US
Mailing Address - Phone:304-928-4464
Mailing Address - Fax:
Practice Address - Street 1:425 LEWIS HARGETT CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3590
Practice Address - Country:US
Practice Address - Phone:859-268-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV93493163W00000X
KY3017780367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse