Provider Demographics
NPI:1801485768
Name:MALLA, BISHAL (FNP)
Entity type:Individual
Prefix:
First Name:BISHAL
Middle Name:
Last Name:MALLA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 CHAIRMANS CT
Mailing Address - Street 2:STE 201A
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-2918
Mailing Address - Country:US
Mailing Address - Phone:240-629-3939
Mailing Address - Fax:240-629-3940
Practice Address - Street 1:10840 LITTLE PATUXENT PKWY STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3254
Practice Address - Country:US
Practice Address - Phone:410-730-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR237810363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily