Basic Information
| Provider Information | |||||||||
| NPI: | 1043746225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IDRIS | ||||||||
| FirstName: | RAMLAT | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15504 CASTLE CT | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207075301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789388801 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2041 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200600002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028656100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2017 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M7710 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | M7710 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA11787 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 209760209 | 05 | TX | MEDICAID |