Healthcare Provider Details

I. General information

NPI: 1003041898
Provider Name (Legal Business Name): TINA MALM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 BROADWAY
EVERETT WA
98201-2321
US

IV. Provider business mailing address

PO BOX 2928
PORTLAND OR
97208-2928
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax: 425-259-8630
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110002949
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number324081
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: