Provider Demographics
NPI:1811188337
Name:MALLORY, KEVIN L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:L
Last Name:MALLORY
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 4110
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-4110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:149 4TH AVE N
Practice Address - Street 2:
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840-9437
Practice Address - Country:US
Practice Address - Phone:509-422-7230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004352363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical