Healthcare Provider Details

I. General information

NPI: 1356743140
Provider Name (Legal Business Name): AMY PATRICIA REARDON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY PATRICIA ROMITO PA-C

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 64226
BALTIMORE MD
21264-4226
US

V. Phone/Fax

Practice location:
  • Phone: 667-214-1718
  • Fax: 410-328-5147
Mailing address:
  • Phone: 667-214-1734
  • Fax: 410-706-6976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT 9108152
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001009954
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0008477
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: