Healthcare Provider Details

I. General information

NPI: 1477152320
Provider Name (Legal Business Name): TESSA MIRJAFARY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date: 08/27/2024
Reactivation Date: 09/16/2024

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
BALTIMORE MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-502-2037
  • Fax: 410-955-0737
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberDX4791
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0009629
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: