Provider Demographics
NPI:1134880453
Name:MAULDIN, TY
Entity type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:MAULDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 W WICKLOW CT
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-3252
Mailing Address - Country:US
Mailing Address - Phone:605-836-1227
Mailing Address - Fax:
Practice Address - Street 1:1316 W WICKLOW CT
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-3252
Practice Address - Country:US
Practice Address - Phone:605-836-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-08
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FL390200000X
NCTAMGC05112013207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5020425893002OtherSS NETWORK ALLIANCE #
CA96440OtherACCME (ACCREDITATION COUNCIL FOR CONTINUING MEDICAL EDUCATION)
NCTAMGC05152013OtherGREENSBORO COLLEGE