Provider Demographics
NPI:1023342813
Name:MALLIN, AVI MEIR SAMUEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:AVI
Middle Name:MEIR SAMUEL
Last Name:MALLIN
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 1:4838 E FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-6538
Mailing Address - Country:US
Mailing Address - Phone:702-845-1200
Mailing Address - Fax:
Practice Address - Street 1:6644 EAST BAYWOOD AVENUE
Practice Address - Street 2:BANNER BAYWOOD MEDICAL CENTER
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-321-4740
Practice Address - Fax:480-321-4565
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant