Healthcare Provider Details

I. General information

NPI: 1548241128
Provider Name (Legal Business Name): KERRY D MALIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 N STATE ROUTE 89
CHINO VALLEY AZ
86323-5695
US

IV. Provider business mailing address

1780 N STATE ROUTE 89
CHINO VALLEY AZ
86323-5695
US

V. Phone/Fax

Practice location:
  • Phone: 928-460-5214
  • Fax:
Mailing address:
  • Phone: 928-460-5214
  • Fax: 928-441-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5167
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: