Provider Demographics
NPI:1629046792
Name:PATCHEL, MALCOLM A (PA-C)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:A
Last Name:PATCHEL
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:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4500
Mailing Address - Fax:850-475-4781
Practice Address - Street 1:550 REDSTONE AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6429
Practice Address - Country:US
Practice Address - Phone:850-682-6122
Practice Address - Fax:850-682-5917
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291925700Medicaid
FLE3861YMedicare PIN
FLP05465Medicare UPIN
FLE38612Medicare ID - Type Unspecified
FLD05465Medicare UPIN