Provider Demographics
NPI:1285692285
Name:MALLORY, BARBARA K (PAC)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:K
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 W NORTH RIVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201
Mailing Address - Country:US
Mailing Address - Phone:509-324-6464
Mailing Address - Fax:509-241-2056
Practice Address - Street 1:322 W NORTH RIVER DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3208
Practice Address - Country:US
Practice Address - Phone:509-324-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003905363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB25216Medicare ID - Type Unspecified