Basic Information
| Provider Information | |||||||||
| NPI: | 1578021739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALAAS | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | STRONG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STRONG | ||||||||
| OtherFirstName: | MALLORY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1701 CURVE CREST BLVD W STE 104 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 CURVE CREST BLVD W STE 104 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2019 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5006-23 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 13031 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.