Healthcare Provider Details

I. General information

NPI: 1356969752
Provider Name (Legal Business Name): RAJU SHRESTHA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5233 KING AVE STE 208
ROSEDALE MD
21237-4003
US

IV. Provider business mailing address

5233 KING AVE STE 208
ROSEDALE MD
21237-4003
US

V. Phone/Fax

Practice location:
  • Phone: 410-918-1525
  • Fax:
Mailing address:
  • Phone: 443-248-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0007502
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: