Provider Demographics
NPI:1275517443
Name:MALY, ALISHA FAY (PA)
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:FAY
Last Name:MALY
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:PO BOX 3043
Mailing Address - Street 2:MEA AEA KENOSH SC
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3043
Mailing Address - Country:US
Mailing Address - Phone:630-734-0200
Mailing Address - Fax:630-734-1560
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:AURORA MEDICAL CENTER
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-697-7000
Practice Address - Fax:630-734-1560
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1690023207P00000X
WI1690-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41987700Medicaid
WI41987700Medicaid
WI0025Medicare ID - Type Unspecified