Provider Demographics
NPI:1144238296
Name:MALLORY, ANGELA (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3160 FOLSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3160 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5219
Practice Address - Country:US
Practice Address - Phone:916-733-5779
Practice Address - Fax:916-733-5940
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16532207R00000X
CAPA16523207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA461137OtherINTERPLAN
CA7765473OtherAETNA
CA1750430OtherGREAT WEST
CA2689216OtherUNITED HEALTHCARE
CAPA16523Medicaid
CA097156OtherHEALTH NET
CA2415601OtherCIGNA
CA90131278OtherPACIFICARE
CA90131278OtherPACIFICARE
CA0PA165230Medicare ID - Type Unspecified