Provider Demographics
NPI:1245862648
Name:GBALA, EMMANUEL A
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:A
Last Name:GBALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 E CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3023
Mailing Address - Country:US
Mailing Address - Phone:443-204-3919
Mailing Address - Fax:410-521-3671
Practice Address - Street 1:117 E CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3023
Practice Address - Country:US
Practice Address - Phone:443-204-3919
Practice Address - Fax:410-521-3671
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR189984363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty