Provider Demographics
NPI:1285142752
Name:KNOLL, MALLERY BUTLER (PA-C)
Entity type:Individual
Prefix:
First Name:MALLERY
Middle Name:BUTLER
Last Name:KNOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6320 N LA CHOLLA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3552
Mailing Address - Country:US
Mailing Address - Phone:520-545-0953
Mailing Address - Fax:520-545-0954
Practice Address - Street 1:350 HERITAGE WAY STE 2100
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3167
Practice Address - Country:US
Practice Address - Phone:406-257-8992
Practice Address - Fax:406-257-8996
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7332363A00000X
390200000X
MTMED-PAC-LIC-103155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program