Basic Information
| Provider Information | |||||||||
| NPI: | 1790206274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATINO | ||||||||
| FirstName: | MALLORY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 COX RD | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230609263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049685700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 417 BALTIMORE PIKE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190643810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844702600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2017 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | OA004186 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | MA059129 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.