Healthcare Provider Details

I. General information

NPI: 1427107580
Provider Name (Legal Business Name): WENDY JO SUBASIC PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 WILKENS AVE SUITE 210
BALTIMORE MD
21229-5072
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 410-644-0929
  • Fax:
Mailing address:
  • Phone: 443-738-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMD0003372
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: