Provider Demographics
NPI:1831194885
Name:MALY, DAVID W (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:MALY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WOODBINE PL
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75693-3907
Mailing Address - Country:US
Mailing Address - Phone:903-291-0011
Mailing Address - Fax:
Practice Address - Street 1:2904 NORTH 4TH STREET
Practice Address - Street 2:LRMC
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-232-3725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX513830367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01536081OtherRAIL ROAD
TX002538908Medicaid
TX002538904Medicaid
TX75-0818167-015OtherTRICARE
TX8K4154Medicare PIN
TX8G6994Medicare PIN
TX439019YQ8AMedicare PIN