Basic Information
| Provider Information | |||||||||
| NPI: | 1295318905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCK | ||||||||
| FirstName: | MACKENZIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8080 E CENTRAL AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672062367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166867327 | ||||||||
| FaxNumber: | 3166861557 | ||||||||
| Practice Location | |||||||||
| Address1: | 8080 E CENTRAL AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672062367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166867327 | ||||||||
| FaxNumber: | 3166861557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2021 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 138572 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.