Basic Information
| Provider Information | |||||||||
| NPI: | 1871868646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MODY | ||||||||
| FirstName: | PUJA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3035 E BALTIMORE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212241349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405296721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 S CATON AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212295201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103686000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110003756 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C0004721 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.