Healthcare Provider Details

I. General information

NPI: 1144652108
Provider Name (Legal Business Name): BRIAN JOEL MALOTT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE 6600
ALBUQUERQUE NM
87106-5411
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-734-4300
  • Fax: 505-724-4384
Mailing address:
  • Phone: 505-272-1476
  • Fax: 505-724-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2013-0044
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2013-0044
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: