Provider Demographics
NPI:1043925639
Name:WARREN-BROTHERS, MALLORY B (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:B
Last Name:WARREN-BROTHERS
Suffix:
Gender:F
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 1:608 OLD ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-3730
Mailing Address - Country:US
Mailing Address - Phone:573-336-5100
Mailing Address - Fax:
Practice Address - Street 1:608 OLD ROUTE 66
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3730
Practice Address - Country:US
Practice Address - Phone:573-336-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO588293247100000X
MO2023011900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist