Healthcare Provider Details

I. General information

NPI: 1588029383
Provider Name (Legal Business Name): GINA NICOLE MALONEY M.H.S., P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA NICOLE LEGER

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NE 10TH ST SUITE 4200
OKLAHOMA CITY OK
73104-5417
US

IV. Provider business mailing address

PO BOX 26901 WP 1290
OKLAHOMA CITY OK
73126-0901
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-1368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2581
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: