Individual
MALLORY FILLMORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
3680 NW SAMARITAN DR, CORVALLIS, OR 97330-3737
(541) 754-1150
Mailing address
444 NW ELKS DR, CORVALLIS, OR 97330-3745
(541) 754-1150
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA174128
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500695157
—
OR
Enumeration date
11/28/2012
Last updated
12/30/2024
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