Healthcare Provider Details

I. General information

NPI: 1275988990
Provider Name (Legal Business Name): DYLAN MALLOY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 CRESTHILL DR STE 120
MINT HILL NC
28227-7924
US

IV. Provider business mailing address

PO BOX 601843
CHARLOTTE NC
28260-1843
US

V. Phone/Fax

Practice location:
  • Phone: 704-438-9479
  • Fax: 704-438-9478
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-09649
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: