1043431638 NPI number — MS. PHYLLIS ANN MALANKA PA-C

Table of content: MS. PHYLLIS ANN MALANKA PA-C (NPI 1043431638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043431638 NPI number — MS. PHYLLIS ANN MALANKA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALANKA
Provider First Name:
PHYLLIS
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043431638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1899 N MARINE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28546-6555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-347-1515
Provider Business Mailing Address Fax Number:
910-347-7982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1202 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28401-7307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-341-3300
Provider Business Practice Location Address Fax Number:
910-251-8824
Provider Enumeration Date:
05/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0010-00818 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)