Provider Demographics
NPI:1073814984
Name:BRESLAW, IRINE (PA)
Entity Type:Individual
Prefix:
First Name:IRINE
Middle Name:
Last Name:BRESLAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:IRINE
Other - Middle Name:
Other - Last Name:VERSHOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9601 PULASKI PARK DR
Mailing Address - Street 2:SUITE 416
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1409
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:410-933-1823
Practice Address - Street 1:9601 PULASKI PARK DR
Practice Address - Street 2:SUITE 416
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220-1409
Practice Address - Country:US
Practice Address - Phone:410-933-5678
Practice Address - Fax:410-933-1823
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD197984Y3PMedicare PIN
MDK858Medicare PIN