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: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17301 E SPRING VALLEY RD STE F
MAYER AZ
86333-4263
US

IV. Provider business mailing address

17301 E SPRING VALLEY RD STE F
MAYER AZ
86333-4263
US

V. Phone/Fax

Practice location:
  • Phone: 928-632-4909
  • Fax: 928-441-2915
Mailing address:
  • Phone: 928-632-4909
  • 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: