Provider Demographics
NPI:1720035652
Name:MALKI, TERESA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:MALKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:LYNN
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:215 S ALLISON AVE
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-3694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 S ALLISON AVE
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-3694
Practice Address - Country:US
Practice Address - Phone:937-376-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-2381363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOPA26891Medicare PIN
OHQ69582Medicare UPIN