Provider Demographics
NPI:1992020259
Name:MALLETTE, PAIGE REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:REBECCA
Last Name:MALLETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:STE 202
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7306
Mailing Address - Country:US
Mailing Address - Phone:970-247-5362
Mailing Address - Fax:970-259-6045
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:STE 202
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-247-5362
Practice Address - Fax:970-259-6045
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA134364207X00000X
CODR.0056893207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB240131Medicare PIN