Basic Information
| Provider Information | |||||||||
| NPI: | 1972771020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLY | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193847898 | ||||||||
| FaxNumber: | 3193840603 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S CLINTON ST STE 168 | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522404034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193847898 | ||||||||
| FaxNumber: | 3193840603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2008 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001836 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | 085003198 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | 001836 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1972771020 | 01 | IA | BC/BS OF IOWA INDIVIDUAL | OTHER | 8122859 | 01 | IL | BCBS OF ILLINOIS | OTHER | 1932193224 | 01 | CLINIC NPI | OTHER | 13238 | 01 | IA | WELLMARK BCBS OF IA | OTHER | 161935 | 01 | IA | HEALTH ALLIANCE | OTHER | 16-1801 | 01 | IA | MEDICARE UGS GROUP # | OTHER | 1932193224 | 05 | IA | MEDICAID | 1972771020 | 05 | IL | MEDICAID | 421060724002 | 05 | IL | MEDICAID |