Provider Demographics
NPI:1558613828
Name:MALLERY, JOHN T (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:MALLERY
Suffix:
Gender:M
Credentials:CRNA
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Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2907
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:DEPARTMENT OF ANESTHESIA
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1535
Practice Address - Country:US
Practice Address - Phone:703-504-3789
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-11-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0024170473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1558613828OtherNPI