Provider Demographics
NPI:1417405416
Name:WIPF, MALLORY (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WIPF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:HOLZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:640 FLORMANN ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4679
Mailing Address - Country:US
Mailing Address - Phone:605-755-3300
Mailing Address - Fax:605-755-5775
Practice Address - Street 1:640 FLORMANN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4679
Practice Address - Country:US
Practice Address - Phone:605-755-3300
Practice Address - Fax:605-755-5775
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant