Basic Information
| Provider Information | |||||||||
| NPI: | 1205321320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALCOM | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | MARSHALL | ||||||||
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| Credential: | MSN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784745600 | ||||||||
| FaxNumber: | 4784716769 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336644 | ||||||||
| FaxNumber: | 4786334295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2018 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 230579 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.