Healthcare Provider Details

I. General information

NPI: 1366492795
Provider Name (Legal Business Name): DAVID MALIGRO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 9TH AVE STE 210
LONGVIEW WA
98632-2465
US

IV. Provider business mailing address

625 9TH AVE STE 210
LONGVIEW WA
98632-2465
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-3400
  • Fax: 360-423-6862
Mailing address:
  • Phone: 360-501-3400
  • Fax: 360-423-6862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003539
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: