Healthcare Provider Details

I. General information

NPI: 1467485284
Provider Name (Legal Business Name): FELICIA T. PRYOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 410-532-4022
  • Fax:
Mailing address:
  • Phone: 856-686-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002625
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: