Healthcare Provider Details

I. General information

NPI: 1760633861
Provider Name (Legal Business Name): AESTHETIC PLASTIC SURGERY OF DELAWARE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 PENNSYLVANIA AVE
WILMINGTON DE
19806-4047
US

IV. Provider business mailing address

1600 PENNSYLVANIA AVE
WILMINGTON DE
19806-4047
US

V. Phone/Fax

Practice location:
  • Phone: 302-656-0214
  • Fax:
Mailing address:
  • Phone: 302-656-0214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberC1000536
License Number StateDE

VIII. Authorized Official

Name: MS. DAWN MICUN
Title or Position: ADMINISTRATOR
Credential:
Phone: 302-656-0214