Basic Information
| Provider Information | |||||||||
| NPI: | 1497093363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOTYCZ | ||||||||
| FirstName: | MALLORIE | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21000 NE 28TH AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059371999 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21000 NE 28TH AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059371999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2013 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PAT9107065 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.