Provider Demographics
NPI:1326135112
Name:MALLIS, MELINDA LISA (PA)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:LISA
Last Name:MALLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3450 WAYNE AVENUE
Mailing Address - Street 2:APT 26E
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2554
Mailing Address - Country:US
Mailing Address - Phone:718-405-2148
Mailing Address - Fax:718-547-4773
Practice Address - Street 1:111 EAST 210TH STREET
Practice Address - Street 2:MONTEFIORE HOSPITAL - TRANSPLANT OFFICE RC
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2554
Practice Address - Country:US
Practice Address - Phone:718-920-4459
Practice Address - Fax:718-547-4773
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001218363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS62252Medicare UPIN
NYOFO561Medicare ID - Type Unspecified