Provider Demographics
NPI:1033821830
Name:HORMONES & IMMUNOLOGY PERSONALIZED MEDICINE
Entity Type:Organization
Organization Name:HORMONES & IMMUNOLOGY PERSONALIZED MEDICINE
Other - Org Name:H&I PERSONALIZED MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAVON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGRUDER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:443-204-1134
Mailing Address - Street 1:9954 SHOSHONE WAY
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-1739
Mailing Address - Country:US
Mailing Address - Phone:443-204-1134
Mailing Address - Fax:
Practice Address - Street 1:100 OWINGS CT STE 12
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-6434
Practice Address - Country:US
Practice Address - Phone:443-204-1134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HORMONES & IMMUNOLOGY PERSONALIZED MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-23
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty