Provider Demographics
NPI:1295216190
Name:KUPPAN, MALAR (NP)
Entity type:Individual
Prefix:
First Name:MALAR
Middle Name:
Last Name:KUPPAN
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5519 W BANFF LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3045
Mailing Address - Country:US
Mailing Address - Phone:623-261-5258
Mailing Address - Fax:
Practice Address - Street 1:5310 W THUNDERBIRD RD STE 202
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4712
Practice Address - Country:US
Practice Address - Phone:623-301-9992
Practice Address - Fax:623-432-7006
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11701363LA2100X, 363LA2200X, 363LG0600X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology