Healthcare Provider Details

I. General information

NPI: 1801131214
Provider Name (Legal Business Name): ASHA THARAKAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 FRANKLIN SQUARE DR STE 209
BALTIMORE MD
21237-3958
US

IV. Provider business mailing address

9105 FRANKLIN SQUARE DR STE 209
BALTIMORE MD
21237-3958
US

V. Phone/Fax

Practice location:
  • Phone: 410-574-1330
  • Fax:
Mailing address:
  • Phone: 410-574-1330
  • Fax: 410-391-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC04844
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: