Healthcare Provider Details

I. General information

NPI: 1336649755
Provider Name (Legal Business Name): MALKIAH ENGELSBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 APOLLO DR APT E
BALTIMORE MD
21209-2923
US

IV. Provider business mailing address

6400 APOLLO DR APT E
BALTIMORE MD
21209-2923
US

V. Phone/Fax

Practice location:
  • Phone: 716-238-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC06742
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: