Provider Demographics
NPI:1093069460
Name:TAWIL, JENNIFER ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:TAWIL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2700 QUARRY LAKE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3746
Mailing Address - Country:US
Mailing Address - Phone:410-377-8900
Mailing Address - Fax:410-377-0576
Practice Address - Street 1:2700 QUARRY LAKE DR STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3746
Practice Address - Country:US
Practice Address - Phone:410-377-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017656363A00000X
FLPA9106854363A00000X
MDC07539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant