Individual
MIKE DESTINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
5401 OLD COURT RD, RANDALLSTOWN, MD 21133-5103
(914) 618-2312
Mailing address
1765 COUNTRYWOOD CT, HYATTSVILLE, MD 20785-4012
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
—
Other
Enumeration date
01/09/2014
Last updated
01/09/2014
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