Provider Demographics
NPI:1356646541
Name:JALLOH-JAMBORIA, ABDUL-MALIK (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ABDUL-MALIK
Middle Name:
Last Name:JALLOH-JAMBORIA
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:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21741-1248
Mailing Address - Country:US
Mailing Address - Phone:800-938-2828
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:301-665-1717
Practice Address - Fax:301-665-1810
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR172198367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD085722OtherAANA ID
MDP00957554OtherRAILROAD MEDICARE PTAN
MD214393Medicare PIN