Provider Demographics
NPI:1740892041
Name:MARPLE COLE, MACKENZIE LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LAUREN
Last Name:MARPLE COLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:LAUREN
Other - Last Name:MARPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:246 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HUGHESVILLE
Practice Address - State:PA
Practice Address - Zip Code:17737-1614
Practice Address - Country:US
Practice Address - Phone:570-584-5144
Practice Address - Fax:570-584-5416
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038386160001Medicaid
PA1J5535OtherMEDICARE