Individual
NJI ADE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2250 HICKORY RD, SUITE 240, PLYMOUTH MEETING, PA 19462-1047
(610) 834-1122
Mailing address
7003 AQUINAS AVE, UPPER MARLBORO, MD 20772-4285
(301) 395-9346
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
LP45028
MD
Other
Enumeration date
11/05/2008
Last updated
11/05/2008
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