Provider Demographics
NPI:1144652108
Name:MALOTT, BRIAN JOEL (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOEL
Last Name:MALOTT
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 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:505-724-4384
Practice Address - Street 1:201 CEDAR ST SE STE 6600
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-5411
Practice Address - Country:US
Practice Address - Phone:505-734-4300
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2013-0044363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16433882Medicaid
NM16433882Medicaid