Provider Demographics
NPI:1497093363
Name:LOTYCZ RAUCH, MALLORIE RENE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MALLORIE
Middle Name:RENE
Last Name:LOTYCZ RAUCH
Suffix:
Gender:
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 1:9605 NW 26TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4987
Mailing Address - Country:US
Mailing Address - Phone:419-360-0284
Mailing Address - Fax:
Practice Address - Street 1:1800 ASTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7399
Practice Address - Country:US
Practice Address - Phone:760-766-1923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-27
Last Update Date:2025-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107065363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHB592ZMedicare PIN