Provider Demographics
NPI:1730174897
Name:SLATON, MALCOLM WALTON (PA-C)
Entity type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:WALTON
Last Name:SLATON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:SLATON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:5704 CAPISTRANO WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80504-9712
Mailing Address - Country:US
Mailing Address - Phone:303-704-6504
Mailing Address - Fax:720-652-4774
Practice Address - Street 1:1014 PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:303-704-6504
Practice Address - Fax:720-652-4774
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO919363A00000X, 363AM0700X
SC521363AM0700X
NC103150363AM0700X
IL212363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212OtherSTATE LICENSE
SC521OtherSTATE LICENSE
CO87986710Medicaid
NC103150OtherSTATE LICENSE
CO919OtherSTATE LICENSE
S77538Medicare UPIN
806835Medicare ID - Type Unspecified