Healthcare Provider Details

I. General information

NPI: 1043683501
Provider Name (Legal Business Name): JACQUELINE SNYDER
Entity Type: Individual
Gender: Female
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

5601 LOCH RAVEN BLVD
BALTIMORE MD
21239-2945
US

IV. Provider business mailing address

11 TRELAWNY CT
LUTHERVILLE MD
21093-4728
US

V. Phone/Fax

Practice location:
  • Phone: 443-444-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0005970
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: