MEDICARE: JOHN W DISTLER FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R147365	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285692418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN W DISTLER FNP

Provider Business Mailing Address
First Line	:	2800 QUARRY LAKE DRIVE
Second Line	:	100
City	:	BALTIMORE
State	:	MD
Zip	:	21209-3770
Country	:	US
Telephone Number	:	410-486-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	844 WASHINGTON ROAD
Second Line	:	SUITE 201
City	:	WESTMINSTER
State	:	MD
Zip	:	21157-3035
Country	:	US
Telephone Number	:	410-857-7900
Fax Number	:	410-857-1150

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	05/30/2012

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