Provider Demographics
NPI:1801141163
Name:MALLIT, JUSTIN ELI (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ELI
Last Name:MALLIT
Suffix:
Gender:M
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 1:425 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3413
Mailing Address - Country:US
Mailing Address - Phone:760-737-6960
Mailing Address - Fax:
Practice Address - Street 1:855 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3819
Practice Address - Country:US
Practice Address - Phone:619-440-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22408363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14158OtherGROUP PTAN
CAHM583ZMedicare UPIN