Healthcare Provider Details

I. General information

NPI: 1063931210
Provider Name (Legal Business Name): TANIA FAKHERI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9199 REISTERSTOWN RD STE 101B
OWINGS MILLS MD
21117-4513
US

IV. Provider business mailing address

9199 REISTERSTOWN RD STE 101B
OWINGS MILLS MD
21117-4513
US

V. Phone/Fax

Practice location:
  • Phone: 443-898-8160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006523
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: