MEDICARE: JISHA S VARGHESE A-GNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	R160402	MD

General Provider Information

NPI Number	:	1881202570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JISHA S VARGHESE A-GNP-C

Provider Business Mailing Address
First Line	:	3257 RAMBLEWOOD RD
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-2445
Country	:	US
Telephone Number	:	443-518-9907
Fax Number	:

Provider Business Practice Location Address
First Line	:	3257 RAMBLEWOOD RD
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-2445
Country	:	US
Telephone Number	:	443-518-9907
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2020
Last Update Date	:	07/19/2020

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