Provider Demographics
NPI:1730190935
Name:MALM, ROGER SCOTT (PA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:SCOTT
Last Name:MALM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 S DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5960
Mailing Address - Country:US
Mailing Address - Phone:208-606-0396
Mailing Address - Fax:208-936-7002
Practice Address - Street 1:824 S DIAMOND ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5960
Practice Address - Country:US
Practice Address - Phone:208-606-0396
Practice Address - Fax:208-936-7002
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-220OtherSTATE LICENSE