Provider Demographics
NPI:1720334543
Name:MALSOM, PAUL D (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:MALSOM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5000 BLACKMORE RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3345
Mailing Address - Country:US
Mailing Address - Phone:307-233-6000
Mailing Address - Fax:307-233-6089
Practice Address - Street 1:5000 BLACKMORE RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3345
Practice Address - Country:US
Practice Address - Phone:307-233-6000
Practice Address - Fax:307-233-6089
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
COPA.0003502363AM0700X
NC0010-04186363AM0700X
WYPA643363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical