Provider Demographics
NPI:1801889787
Name:MALLARI, PAUL (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MALLARI
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 1:79 CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:ASSONET
Mailing Address - State:MA
Mailing Address - Zip Code:02702-1377
Mailing Address - Country:US
Mailing Address - Phone:401-529-7787
Mailing Address - Fax:508-674-8880
Practice Address - Street 1:1526 ATWOOD AVE STE 220
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3289
Practice Address - Country:US
Practice Address - Phone:401-396-2227
Practice Address - Fax:401-421-1120
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00270363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI409374OtherBLUE CHIP
RI0000030808OtherBC BS OF RHODE ISLAND
RIPM54778Medicaid
RIP53271Medicare UPIN
RI979003536Medicare ID - Type UnspecifiedMEDICARE