Provider Demographics
NPI:1225790553
Name:HOBACK, MACKENNA LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENNA
Middle Name:LOUISE
Last Name:HOBACK
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 1:3292 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-1730
Mailing Address - Country:US
Mailing Address - Phone:303-588-1047
Mailing Address - Fax:
Practice Address - Street 1:5600 S QUEBEC ST STE 312A
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2208
Practice Address - Country:US
Practice Address - Phone:303-436-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant