Provider Demographics
NPI:1861894651
Name:WIPF, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WIPF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0900
Mailing Address - Country:US
Mailing Address - Phone:605-336-2140
Mailing Address - Fax:605-336-1677
Practice Address - Street 1:4011 W BENSON RD
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57107-0104
Practice Address - Country:US
Practice Address - Phone:605-322-1500
Practice Address - Fax:605-322-1510
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant