Healthcare Provider Details

I. General information

NPI: 1821707852
Provider Name (Legal Business Name): JAN PATRICK MALPAYA LLANDA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 RIVERVIEW AVE STE 202
NORFOLK VA
23510-1065
US

IV. Provider business mailing address

301 RIVERVIEW AVE STE 202A
NORFOLK VA
23510-1065
US

V. Phone/Fax

Practice location:
  • Phone: 757-252-9140
  • Fax:
Mailing address:
  • Phone: 757-252-9140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12783
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009097
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: