=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386331676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOUND MD PA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2023
-----------------------------------------------------
Last Update Date | 04/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 W SPROUL RD STE 106
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19064-1254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-479-4217
-----------------------------------------------------
Fax | 888-557-9724
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8133 LEESBURG PIKE STE 630
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-479-4217
-----------------------------------------------------
Fax | 888-557-9724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AZMAT HUSAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-300-3830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WW0000X
-----------------------------------------------------
Taxonomy Name | Wound Care Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------