Healthcare Provider Details

I. General information

NPI: 1013330851
Provider Name (Legal Business Name): DAMA RETER YEKESON-KOFFA RN, SRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE ANESTHESIA DEPARTMENT BAYVIEW MEDICAL CENTER
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

4940 EASTERN AVE ANESTHESIA DEPARTMENT BAYVIEW MEDICAL CENTER
BALTIMORE MD
21224-2735
US

V. Phone/Fax

Practice location:
  • Phone: 443-694-8960
  • Fax: 410-356-5821
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR181175
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: