Healthcare Provider Details

I. General information

NPI: 1487034401
Provider Name (Legal Business Name): PATRICK MALTBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1349 E DUVAL ST 4
LAKE CITY FL
32055-3651
US

IV. Provider business mailing address

1349 E DUVAL ST 4
LAKE CITY FL
32055-3651
US

V. Phone/Fax

Practice location:
  • Phone: 828-246-5272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE3172772
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2014-330-01
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA314827
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: