Provider Demographics
NPI:1679543946
Name:MALSTROM, SARAH L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:L
Last Name:MALSTROM
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 1:525 JAMESTOWN AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128
Mailing Address - Country:US
Mailing Address - Phone:215-483-3666
Mailing Address - Fax:
Practice Address - Street 1:130 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-9756
Practice Address - Country:US
Practice Address - Phone:570-454-2435
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003600L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP40331Medicare UPIN
PA051044Medicare ID - Type UnspecifiedHAZLETON
PA051147Medicare ID - Type UnspecifiedPHILADELPHIA