Healthcare Provider Details

I. General information

NPI: 1306428792
Provider Name (Legal Business Name): GARTH GREY FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GARTH GWIAZDOWSKI RN

II. Dates (important events)

Enumeration Date: 04/25/2021
Last Update Date: 02/05/2024
Certification Date: 12/13/2023
Deactivation Date: 11/30/2021
Reactivation Date: 12/22/2021

III. Provider practice location address

18121 GEORGIA AVE STE 103
OLNEY MD
20832-1437
US

IV. Provider business mailing address

18121 GEORGIA AVE STE 103
OLNEY MD
20832-1437
US

V. Phone/Fax

Practice location:
  • Phone: 301-933-5050
  • Fax: 301-949-3262
Mailing address:
  • Phone: 301-933-5050
  • Fax: 301-949-3262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR242260
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR242260
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: