Provider Demographics
NPI:1992904148
Name:MALFATTO, MICHAEL A (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:MALFATTO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:A
Other - Last Name:MALFATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-713-1779
Mailing Address - Fax:513-854-9921
Practice Address - Street 1:7277 SMITHS MILL RD STE 200
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8195
Practice Address - Country:US
Practice Address - Phone:614-221-6331
Practice Address - Fax:614-221-9042
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103872Medicaid