Provider Demographics
NPI:1972060598
Name:LITWILLER, MALLORY (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LITWILLER
Suffix:
Gender:F
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 1:1028 S WEST SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-8656
Mailing Address - Country:US
Mailing Address - Phone:231-631-2211
Mailing Address - Fax:
Practice Address - Street 1:1447 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4727
Practice Address - Country:US
Practice Address - Phone:989-583-4220
Practice Address - Fax:989-583-4287
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008957363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant