Healthcare Provider Details

I. General information

NPI: 1861439309
Provider Name (Legal Business Name): NATELEGE T WARDLOW PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 W BELVEDERE AVE STE 42
BALTIMORE MD
21215-5224
US

IV. Provider business mailing address

2435 W BELVEDERE AVE STE 42
BALTIMORE MD
21215-5224
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-5547
  • Fax: 410-601-5835
Mailing address:
  • Phone: 410-601-5547
  • Fax: 410-601-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002886
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: