Provider Demographics
NPI:1487438560
Name:BONNEWITZ, MACKENZIE (PA-S)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BONNEWITZ
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 E 8TH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4661
Mailing Address - Country:US
Mailing Address - Phone:918-906-6523
Mailing Address - Fax:
Practice Address - Street 1:1211 E 8TH ST APT 201
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-4661
Practice Address - Country:US
Practice Address - Phone:918-906-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant