Provider Demographics
NPI:1932819653
Name:BANGURA, MALIK I (PA)
Entity Type:Individual
Prefix:
First Name:MALIK
Middle Name:I
Last Name:BANGURA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:MALIK
Other - Middle Name:I
Other - Last Name:BANGURA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MALIK BANGURA
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:440-550-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA363AM0700X
MDC08801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical