Provider Demographics
NPI:1619605722
Name:KASSAB, MACKENZY LEE (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZY
Middle Name:LEE
Last Name:KASSAB
Suffix:
Gender:
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 1:4421 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-1591
Mailing Address - Country:US
Mailing Address - Phone:248-412-3120
Mailing Address - Fax:
Practice Address - Street 1:31393 W 13 MILE RD STE 105
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2232
Practice Address - Country:US
Practice Address - Phone:734-331-6037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601011399OtherMI PHYSICIAN ASSISTANT LICENSE