1679821268 NPI number — AMBER L SPRADLIN PA-C

Table of content: AMBER L SPRADLIN PA-C (NPI 1679821268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679821268 NPI number — AMBER L SPRADLIN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPRADLIN
Provider First Name:
AMBER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679821268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 THOMAS JOHNSON DR
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21702-4397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-668-9988
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 SHERRY LN
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PRINCE FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20678-3232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-414-9229
Provider Business Practice Location Address Fax Number:
410-414-9339
Provider Enumeration Date:
08/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  C0004821 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C0004821 . This is a "STATE LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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