Provider Demographics
NPI:1972250504
Name:KEUTZER, MACKENZIE JO (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:JO
Last Name:KEUTZER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:JO
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:901 E 104TH ST # 3000S
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3241
Practice Address - Country:US
Practice Address - Phone:816-932-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023029157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty