Provider Demographics
NPI:1093231755
Name:GENTRY, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:GENTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 FOLKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047-1407
Mailing Address - Country:US
Mailing Address - Phone:443-299-9093
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL ST STE POB 802
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:443-299-9093
Practice Address - Fax:443-299-9093
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical