Provider Demographics
NPI:1710086608
Name:MALLORY, NORMAN ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NORMAN
Middle Name:ROBERT
Last Name:MALLORY
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8941
Mailing Address - Fax:207-777-4397
Practice Address - Street 1:360 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3979
Practice Address - Country:US
Practice Address - Phone:207-907-3550
Practice Address - Fax:207-907-3562
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-02-03
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Provider Licenses
StateLicense IDTaxonomies
MEPA-692363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
016001944Medicare UPIN