Provider Demographics
NPI:1235560475
Name:MALLOY, CHRISTOPHER THOMAS (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:MALLOY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5622
Mailing Address - Country:US
Mailing Address - Phone:610-628-8372
Mailing Address - Fax:610-628-8648
Practice Address - Street 1:230 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1121
Practice Address - Country:US
Practice Address - Phone:215-762-7922
Practice Address - Fax:215-762-8656
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR15663400163W00000X
PARN600018367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101375OtherAANA