Individual
GREGORY MALLETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
800 E DAWSON ST, TYLER, TX 75701
(903) 606-4522
Mailing address
PO BOX 841656, DALLAS, TX 75284-1656
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
826622
TX
367500000X
Certified Registered Nurse Anesthetist
RN117800
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
314440403
—
TX
01
—
314440406
MEDICARE
TX
01
—
75-2771569-008
TRICARE
TX
01
—
799488
MEDICARE
TX
01
—
8683UK
BCBS
TX
01
—
8JM831
BCBS
TX
01
—
P02245621
MEDICARE RAIL ROAD
TX
Enumeration date
01/05/2012
Last updated
05/01/2024
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