Provider Demographics
NPI:1528634045
Name:MYERS, MALLORY DENHAM (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:DENHAM
Last Name:MYERS
Suffix:
Gender:F
Credentials:PA-C
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:5153 NORTH 9TH AVENUE
Practice Address - Street 2:4TH FLOOR - PEDIATRIC ORTHOPEDICS
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504
Practice Address - Country:US
Practice Address - Phone:850-416-1304
Practice Address - Fax:850-416-1302
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPAX000018146363A00000X
FLPA9114469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant