Provider Demographics
NPI:1043746225
Name:IDRIS, RAMLAT (PA)
Entity Type:Individual
Prefix:
First Name:RAMLAT
Middle Name:
Last Name:IDRIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15504 CASTLE CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5301
Mailing Address - Country:US
Mailing Address - Phone:678-938-8801
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-0002
Practice Address - Country:US
Practice Address - Phone:202-865-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-07
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7710207P00000X, 208000000X
363A00000X
TXPA11787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209760209Medicaid