Provider Demographics
NPI:1669705802
Name:MALONE, LINDA (PA)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MALONE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-5915
Mailing Address - Fax:757-446-5089
Practice Address - Street 1:721 FAIRFAX AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-2007
Practice Address - Country:US
Practice Address - Phone:757-446-5915
Practice Address - Fax:757-446-5089
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1669705802Medicaid
VA-017OtherTRICARE/CHAMPUS
VA1669705802Medicaid