Healthcare Provider Details

I. General information

NPI: 1770560450
Provider Name (Legal Business Name): PERCIVAL CARLOS HARGROVE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

IV. Provider business mailing address

13309 WHITAKER PARK DR
BRANDYWINE MD
20613-5688
US

V. Phone/Fax

Practice location:
  • Phone: 240-612-1856
  • Fax:
Mailing address:
  • Phone: 302-331-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005080
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC0005080
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: