Healthcare Provider Details

I. General information

NPI: 1942688379
Provider Name (Legal Business Name): EVAN NATHAN DICKSTEIN NP-PMH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 BUCKEYSTOWN PIKE
FREDERICK MD
21704-8370
US

IV. Provider business mailing address

13121 BROOK LANE
HAGERSTOWN MD
21742-1945
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-0330
  • Fax: 301-733-4038
Mailing address:
  • Phone: 301-733-0330
  • Fax: 301-733-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR200789
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR200789
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: