Provider Demographics
NPI:1184152225
Name:MALLOY-MCCOY, MARTY ELIJAH (APRN, CRNA, CNP)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:ELIJAH
Last Name:MALLOY-MCCOY
Suffix:
Gender:M
Credentials:APRN, CRNA, CNP
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:MARTIN
Other - Last Name:MCCOY
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:658 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2974
Mailing Address - Country:US
Mailing Address - Phone:740-285-6529
Mailing Address - Fax:
Practice Address - Street 1:1320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:220-564-4226
Practice Address - Fax:220-564-4226
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0027784363LF0000X, 363L00000X
OHAPRNCRNA019508367500000X
OHAPRN.CRNA.019508367500000X
OHRN382689163W00000X
OHRN.382689163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner