Healthcare Provider Details

I. General information

NPI: 1275911307
Provider Name (Legal Business Name): SUJA ABRAHAM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 OLD YORK RD
PHILADELPHIA PA
19126-2114
US

IV. Provider business mailing address

1922 GREENSPRING DR SUITE 6
TIMONIUM MD
21093-7603
US

V. Phone/Fax

Practice location:
  • Phone: 215-424-4090
  • Fax:
Mailing address:
  • Phone: 410-308-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP014952
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: