Provider Demographics
NPI:1790206274
Name:PATINO, MALLORY (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:PATINO
Suffix:
Gender:F
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 1:324 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7150
Mailing Address - Country:US
Mailing Address - Phone:302-738-4300
Mailing Address - Fax:
Practice Address - Street 1:324 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7150
Practice Address - Country:US
Practice Address - Phone:302-738-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004186363AM0700X
PAMA059129363AM0700X
DEC5-0011878363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical