Provider Demographics
NPI:1548884380
Name:BAUMAN, MCKENZIE ANN
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ANN
Last Name:BAUMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 VINEHAVEN DR NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2438
Mailing Address - Country:US
Mailing Address - Phone:704-783-1840
Mailing Address - Fax:
Practice Address - Street 1:1070 VINEHAVEN DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2438
Practice Address - Country:US
Practice Address - Phone:704-783-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-06
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
NC0010-11311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant