Healthcare Provider Details

I. General information

NPI: 1922771252
Provider Name (Legal Business Name): RAQUEL TANZSWA HALL PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

IV. Provider business mailing address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

V. Phone/Fax

Practice location:
  • Phone: 240-612-1148
  • Fax:
Mailing address:
  • Phone: 240-612-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009013
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: