Basic Information
| Provider Information | |||||||||
| NPI: | 1730711417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EITER | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178651462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1205 S MAIN ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463073677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196620077 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2020 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 10003365A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.