MEDICARE: JESSICA C MALCA-PASTAKIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1105167	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1105167	OTHER	TX	TEAS LICENSE

General Provider Information

NPI Number	:	1518685957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA C MALCA-PASTAKIA

Provider Business Mailing Address
First Line	:	3505 SUMMERHILL RD STE 5
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-3596
Country	:	US
Telephone Number	:	903-710-1400
Fax Number	:	903-710-1500

Provider Business Practice Location Address
First Line	:	3505 SUMMERHILL RD STE 5
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-3596
Country	:	US
Telephone Number	:	903-710-1400
Fax Number	:	903-710-1500

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	12/01/2025

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Directions to “ JESSICA C MALCA-PASTAKIA ” Practice Location

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