Provider Demographics
NPI:1174565246
Name:HALLECK, MARY A (PA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:HALLECK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1714 SW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-1227
Mailing Address - Country:US
Mailing Address - Phone:352-509-9900
Mailing Address - Fax:844-388-6186
Practice Address - Street 1:1714 SW 17TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-1227
Practice Address - Country:US
Practice Address - Phone:352-509-9900
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0229363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010176Medicaid
AP2602Medicare ID - Type Unspecified
NH30010176Medicaid
P49109Medicare UPIN