Provider Demographics
NPI:1699149906
Name:MCCOY, MALLORY LAKE (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LAKE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 LAKE BOONE TRL STE 1B
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7503
Mailing Address - Country:US
Mailing Address - Phone:919-781-1800
Mailing Address - Fax:919-781-1899
Practice Address - Street 1:4601 LAKE BOONE TRL STE 1B
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7503
Practice Address - Country:US
Practice Address - Phone:919-781-1800
Practice Address - Fax:919-781-1899
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant