Provider Demographics
NPI:1982680658
Name:MALLOY, WILLIAM JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:MALLOY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1299 OLENTANGY RIVER RD
Mailing Address - Street 2:STE 103
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3135
Mailing Address - Country:US
Mailing Address - Phone:614-566-4278
Mailing Address - Fax:614-566-5424
Practice Address - Street 1:111 S GRANT AVE
Practice Address - Street 2:FL 3
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4701
Practice Address - Country:US
Practice Address - Phone:614-566-8808
Practice Address - Fax:614-566-9503
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OHRN-169856367500000X
OHNA-01538367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered