Provider Demographics
NPI:1912404401
Name:MALONE, REGINALD MARTINEZ (PA-C)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:MARTINEZ
Last Name:MALONE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 WHITE ST NW STE 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1054
Mailing Address - Country:US
Mailing Address - Phone:470-793-0208
Mailing Address - Fax:
Practice Address - Street 1:175 WHITE ST NW STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1054
Practice Address - Country:US
Practice Address - Phone:470-793-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021986363A00000X, 363AM0700X, 363AS0400X
GA9381363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty