Healthcare Provider Details

I. General information

NPI: 1790206274
Provider Name (Legal Business Name): MALLORY PATINO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E MAIN ST
NEWARK DE
19711-7150
US

IV. Provider business mailing address

324 E MAIN ST
NEWARK DE
19711-7150
US

V. Phone/Fax

Practice location:
  • Phone: 302-738-4300
  • Fax:
Mailing address:
  • Phone: 302-738-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA004186
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA059129
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC5-0011878
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: