Provider Demographics
NPI:1114299930
Name:VALLON, MOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:VALLON
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 1:575 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-6102
Mailing Address - Country:US
Mailing Address - Phone:212-746-7576
Mailing Address - Fax:
Practice Address - Street 1:520 E 70TH ST # 341
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-9800
Practice Address - Country:US
Practice Address - Phone:212-746-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015456-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1103150.OtherNCCPA
NY015456-1OtherNY STATE LICENSE