Healthcare Provider Details

I. General information

NPI: 1710949003
Provider Name (Legal Business Name): LARRY A WASKOW PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1838 GREENE TREE RD SUITE 460
BALTIMORE MD
21208-6391
US

IV. Provider business mailing address

25 CROSSROADS DR SUITE 306
OWINGS MILLS MD
21117-5421
US

V. Phone/Fax

Practice location:
  • Phone: 410-581-1600
  • Fax:
Mailing address:
  • Phone: 410-581-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0000274
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: