Basic Information
| Provider Information | |||||||||
| NPI: | 1821079997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERIATRIC MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2434 W BELVEDERE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106012246 | ||||||||
| FaxNumber: | 4106012924 | ||||||||
| Practice Location | |||||||||
| Address1: | 2434 W BELVEDERE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106012246 | ||||||||
| FaxNumber: | 4106012924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STANTON | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | LARAY | ||||||||
| AuthorizedOfficialTitleorPosition: | CRNP | ||||||||
| AuthorizedOfficialTelephone: | 4106012246 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R111052 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.