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General NPI Number Information
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NPI Number | 1033590724
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Entity Type | Organization
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Legal Business Name | GW THE MEDICAL FACULTY ASSOCIATE
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Dates
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Enumeration Date | 06/18/2015
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Last Update Date | 06/18/2015
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Provider Practice Location Address
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Address Line | 2150 PENNSYLVANIA AVE NW DEPARTMENT OF SURGERY, SUITE 6B-412
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City | WASHINGTON
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State | DC
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Zip | 20037-3201
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Country | US
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Telephone | 202-741-3225
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Fax |
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Provider Business Mailing Address
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Address Line | 10401 GROSVENOR PL APT 1311
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City | ROCKVILLE
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State | MD
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Zip | 20852-4646
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Country | US
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Telephone | 240-481-3356
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MR. ROGER MAGBOO BRUCAL
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Credential | AGPCNP-BC
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Telephone | 240-481-3356
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN1004515
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License Number State | DC
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