Provider Demographics
NPI:1821040619
Name:MALONE, WILLIAM MARTIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:MARTIN
Last Name:MALONE
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 950927
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32795-0927
Mailing Address - Country:US
Mailing Address - Phone:407-328-0825
Mailing Address - Fax:407-322-5478
Practice Address - Street 1:601 E ROLLINS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-303-6611
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2340363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3632Medicare ID - Type UnspecifiedTHIS # HAS SUFFIX A-Z
FLE2584Medicare ID - Type UnspecifiedTHIS # HAS SUFFIX A-Z
FLE5446Medicare ID - Type UnspecifiedTHIS # HAS SUFFIX A-Z