Basic Information
| Provider Information | |||||||||
| NPI: | 1033590724 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GW THE MEDICAL FACULTY ASSOCIATE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10401 GROSVENOR PL | ||||||||
| Address2: | APT 1311 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404813356 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2150 PENNSYLVANIA AVE NW | ||||||||
| Address2: | DEPARTMENT OF SURGERY, SUITE 6B-412 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200373201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027413225 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | BRUCAL | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | MAGBOO | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 2404813356 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | AGPCNP-BC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN1004515 | DC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.