Provider Demographics
NPI:1114172806
Name:MALONE-TRIM, MOLLY JANE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JANE
Last Name:MALONE-TRIM
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:ADMINISTRATIVE SERVICES
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-212-9113
Mailing Address - Fax:
Practice Address - Street 1:50 LEROY ST
Practice Address - Street 2:ADMINISTRATIVE SERVICES
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1786
Practice Address - Country:US
Practice Address - Phone:315-212-9113
Practice Address - Fax:315-261-6021
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY23013000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant