Healthcare Provider Details

I. General information

NPI: 1588235311
Provider Name (Legal Business Name): MALLORY CAST PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MAIN ST
DANVILLE IN
46122-1948
US

IV. Provider business mailing address

2520 DOVER CT
LEBANON IN
46052-8820
US

V. Phone/Fax

Practice location:
  • Phone: 317-718-4676
  • Fax:
Mailing address:
  • Phone: 765-481-1748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10003703A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: