Healthcare Provider Details

I. General information

NPI: 1730552118
Provider Name (Legal Business Name): CHASE NEITZKE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

601 S PACA ST APARTMENT 1
BALTIMORE MD
21230-2432
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0453
  • Fax:
Mailing address:
  • Phone: 410-570-3632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005967
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: