Healthcare Provider Details

I. General information

NPI: 1609590223
Provider Name (Legal Business Name): RYLEIGH MARIE ETZWEILER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

21278 MEADOWSWEET CT
ASHBURN VA
20147-5404
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 571-442-6507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC08651
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC0008651
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: