Provider Demographics
NPI:1487034401
Name:MALTBA, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MALTBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 E DUVAL ST
Mailing Address - Street 2:4
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1349 E DUVAL ST
Practice Address - Street 2:4
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3651
Practice Address - Country:US
Practice Address - Phone:828-246-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
E3172772146N00000X
172A00000X, 172V00000X, 174H00000X, 374T00000X, 374U00000X, 390200000X
NC2014-330-01175T00000X
FLCNA314827376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No175T00000XOther Service ProvidersPeer Specialist
No374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program