Healthcare Provider Details

I. General information

NPI: 1275048332
Provider Name (Legal Business Name): JAN GASPAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W BELVEDERE AVE
BALTIMORE MD
21215-5216
US

IV. Provider business mailing address

4627 AUTUMN WOODS WAY
ELLICOTT CITY MD
21043-6771
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-9000
  • Fax:
Mailing address:
  • Phone: 213-663-3860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: