Provider Demographics
NPI:1164456984
Name:MALONE, MARK D (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:D
Last Name:MALONE
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 1:1925 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:303-776-1234
Mailing Address - Fax:
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:303-776-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72328541Medicaid
CO810907Medicare UPIN
COS18359Medicare UPIN
CO810907Medicare PIN
CO810907Medicare UPIN
COP00264312Medicare ID - Type UnspecifiedRAILROAD
CO810907Medicare Oscar/Certification