Basic Information
| Provider Information | |||||||||
| NPI: | 1104478080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUBBARD | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | MSC 8109-05-06 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143622280 | ||||||||
| FaxNumber: | 8883528360 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BARNES JEWISH HOSPITAL PLZ | ||||||||
| Address2: | DIV SURG TRANSPLANT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147479889 | ||||||||
| FaxNumber: | 3143614197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2019 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2020034088 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 220090497 | 05 | MO | MEDICAID |