Provider Demographics
NPI:1396289849
Name:MBAH, ATIA (FNP)
Entity type:Individual
Prefix:
First Name:ATIA
Middle Name:
Last Name:MBAH
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 1:1456 PANGBOURNE WAY
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1376
Mailing Address - Country:US
Mailing Address - Phone:210-379-4058
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-7081
Practice Address - Country:US
Practice Address - Phone:912-435-5599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162367163WP2201X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care