Provider Demographics
NPI:1750570255
Name:MALLAS, CHEYANNE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:CHEYANNE
Middle Name:
Last Name:MALLAS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N KINGS RD
Mailing Address - Street 2:SUITE 221
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4352
Mailing Address - Country:US
Mailing Address - Phone:917-478-3405
Mailing Address - Fax:
Practice Address - Street 1:950 N KINGS RD
Practice Address - Street 2:SUITE 221
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4352
Practice Address - Country:US
Practice Address - Phone:917-478-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1076908363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical