Provider Demographics
NPI:1386092377
Name:HALUPA, MACKENZIE MOORE (PA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MOORE
Last Name:HALUPA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:MOORE
Other - Last Name:VILLARREAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:
Practice Address - Street 1:1250 S CEDAR CREST BLVD STE 205
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6271
Practice Address - Country:US
Practice Address - Phone:610-402-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA0588296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant