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NPI Code Detail

MEDICARE: MALLORY WIPF PA-C

MEDICARE: MALLORY WIPF PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant1057SD

General Provider Information

NPI Number : 1417405416
Entity Type Code : Individual
Provider Name (Legal Business Name) : MALLORY WIPF PA-C
Provider Business Mailing Address
First Line : 717 SAINT FRANCIS ST
Second Line :
City : RAPID CITY
State : SD
Zip : 57701-4677
Country : US
Telephone Number : 605-342-2880
Fax Number : 833-468-4799
Provider Business Practice Location Address
First Line : 717 SAINT FRANCIS STREET
Second Line :
City : RAPID CITY
State : SD
Zip : 57701-4677
Country : US
Telephone Number : 605-342-2880
Fax Number : 833-468-4799
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/19/2016
Last Update Date : 05/04/2026

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Directions to “ MALLORY WIPF PA-C” Practice Location

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