Most Relevant Information
Provider Data
| NPI Number: | 1003041898 |
| Provider Name: | TINA MALM PA |
| Entity Type: | Individual |
| Taxonomy Code: | 363AM0700X |
| Specialty: | Physician Assistant |
| License Number: | 0110002949 |
Most Important Dates
| Enumeration Date: | 05/21/2009 |
| Last Updated: | 09/22/2021 |
Provider Practice Location
1668 US-51 N
PONCHATOULA
LA
70454
Practice Location Phone/Fax
| Phone: | 9854014022 |
| Fax: | 9854014023 |
Provider Mailing Location
PO BOX 3360
PORTLAND
OR
972083360
Provider Mailing Phone/Fax
| Phone: | |
| Fax: |