Provider Demographics
NPI:1578021739
Name:HALAAS, MALLORY STRONG (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:STRONG
Last Name:HALAAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:STRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1701 CURVE CREST BLVD W STE 104
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6181
Mailing Address - Country:US
Mailing Address - Phone:651-439-8807
Mailing Address - Fax:651-439-0232
Practice Address - Street 1:1701 CURVE CREST BLVD W STE 104
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6181
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5006-23363A00000X
MN13031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant