Provider Demographics
NPI:1780992230
Name:RACOSKI, MALLORY KAY (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KAY
Last Name:RACOSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:KAY
Other - Last Name:WINTERMUTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5950 SR 6 FL 4
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-7905
Mailing Address - Country:US
Mailing Address - Phone:570-836-6808
Mailing Address - Fax:570-836-5536
Practice Address - Street 1:5950 SR 6 FL 4
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657
Practice Address - Country:US
Practice Address - Phone:570-836-6808
Practice Address - Fax:570-836-5536
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054645363AM0700X
PAOA004422363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical