Provider Demographics
NPI:1053141150
Name:WALZ, MCKENZIE PAIGE (PA)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:PAIGE
Last Name:WALZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 HICKORY TURN
Mailing Address - Street 2:
Mailing Address - City:GOODFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61742-9703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-672-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant