Provider Demographics
NPI:1548241128
Name:MALIN, KERRY D (PA-C)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:D
Last Name:MALIN
Suffix:
Gender:M
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 1:17301 E SPRING VALLEY RD STE F
Mailing Address - Street 2:
Mailing Address - City:MAYER
Mailing Address - State:AZ
Mailing Address - Zip Code:86333-4263
Mailing Address - Country:US
Mailing Address - Phone:928-632-4909
Mailing Address - Fax:928-441-2915
Practice Address - Street 1:17301 E SPRING VALLEY RD STE F
Practice Address - Street 2:
Practice Address - City:MAYER
Practice Address - State:AZ
Practice Address - Zip Code:86333-4263
Practice Address - Country:US
Practice Address - Phone:928-632-4909
Practice Address - Fax:928-441-2915
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5167363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1548241128Medicaid
NVP00942209OtherRAILROAD MEDICARE
NVCW726YMedicare PIN
NVCW726XMedicare PIN