Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 125.076103 | IL |
Y | 111NI0900X | Internist | 125.076103 | IL |
NPI | 1003361171 |
---|---|
Provider Name | Costner Mckenzie |
First Address | New York, NY 10016-6402 |
Second Address | New York, NY 10016-6402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2016 |
Last Update Date | 24/06/2021 |