Provider Demographics
NPI:1124392154
Name:KRISPINSKY, MALLORY E (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:E
Last Name:KRISPINSKY
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 1:2111 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2138
Mailing Address - Country:US
Mailing Address - Phone:740-566-4621
Mailing Address - Fax:740-566-4622
Practice Address - Street 1:2111 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2138
Practice Address - Country:US
Practice Address - Phone:740-566-4621
Practice Address - Fax:740-566-4622
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1124392154Medicaid