Healthcare Provider Details

I. General information

NPI: 1255852547
Provider Name (Legal Business Name): MALAIKA LOUDEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 W BROADWAY AVE
JACKSON WY
83001-8639
US

IV. Provider business mailing address

970 W. BROADWAY STE. E #398
JACKSON WY
83001
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-8002
  • Fax:
Mailing address:
  • Phone: 307-413-7757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: