Provider Demographics
NPI:1689683047
Name:MALLARI, ERIN E (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:E
Last Name:MALLARI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:E
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:
Practice Address - Street 1:2780 CLEVELAND AVE
Practice Address - Street 2:SUITE 702
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5858
Practice Address - Country:US
Practice Address - Phone:239-343-3474
Practice Address - Fax:239-343-2968
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLG171OtherMEDICARE
FL292574500Medicaid
FLY01T5OtherBLUE CROSS BLUE SHIELD