Provider Demographics
NPI:1760509095
Name:MALL, NATHAN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ANDREW
Last Name:MALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S KIRKWOOD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6161
Mailing Address - Country:US
Mailing Address - Phone:314-991-4335
Mailing Address - Fax:
Practice Address - Street 1:333 S KIRKWOOD RD STE 200
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6161
Practice Address - Country:US
Practice Address - Phone:314-991-4335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012011153207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery