Provider Demographics
NPI:1114982386
Name:MALOTT, THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MALOTT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 W 12TH ST
Mailing Address - Street 2:STE. 103
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1653
Mailing Address - Country:US
Mailing Address - Phone:765-475-2316
Mailing Address - Fax:
Practice Address - Street 1:285 W 12TH ST
Practice Address - Street 2:STE 112
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1653
Practice Address - Country:US
Practice Address - Phone:765-475-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000716A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ31778Medicare UPIN
IN221840IMedicare PIN