Provider Demographics
NPI:1548014756
Name:JOHNSON, MCKENZIE RAE (PA-C)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
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 1:2517 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-3219
Mailing Address - Country:US
Mailing Address - Phone:814-414-7681
Mailing Address - Fax:
Practice Address - Street 1:1800 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6701
Practice Address - Country:US
Practice Address - Phone:814-231-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant