Healthcare Provider Details

I. General information

NPI: 1164091807
Provider Name (Legal Business Name): JESSE WAKEFIELD SHARP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 S BRADFORD ST
BALTIMORE MD
21224-3605
US

IV. Provider business mailing address

521 S BRADFORD ST
BALTIMORE MD
21224-3605
US

V. Phone/Fax

Practice location:
  • Phone: 585-694-4786
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10003372A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: