Provider Demographics
NPI:1164188520
Name:DALLAIRE, MACKENZIE CAROLYN WALTZ (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:CAROLYN WALTZ
Last Name:DALLAIRE
Suffix:
Gender:F
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 1:1601 HADDON AVE # A
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-3109
Mailing Address - Country:US
Mailing Address - Phone:856-757-3840
Mailing Address - Fax:
Practice Address - Street 1:1601 HADDON AVE # A
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3109
Practice Address - Country:US
Practice Address - Phone:856-757-3840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
NJ25MP00728700363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program