Provider Demographics
NPI:1144550799
Name:MALCOLM, KINGSLEY L (CRNA)
Entity type:Individual
Prefix:MR
First Name:KINGSLEY
Middle Name:L
Last Name:MALCOLM
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 1:2824 RADER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-5748
Mailing Address - Country:US
Mailing Address - Phone:615-424-3918
Mailing Address - Fax:
Practice Address - Street 1:1001 WEST ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-9703
Practice Address - Country:US
Practice Address - Phone:315-493-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY511702-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered