Provider Demographics
NPI:1902379548
Name:SIEVERS, MALLORY LANGELL (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LANGELL
Last Name:SIEVERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:LANGELL
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:661-803-3654
Mailing Address - Fax:
Practice Address - Street 1:28253 BRANCH RD
Practice Address - Street 2:
Practice Address - City:CASTAIC
Practice Address - State:CA
Practice Address - Zip Code:91384-3005
Practice Address - Country:US
Practice Address - Phone:661-803-3654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant