Provider Demographics
NPI:1336135110
Name:SCHRADER, JEFFREY LYNN (CERTIFIED REGISTERED)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LYNN
Last Name:SCHRADER
Suffix:
Gender:M
Credentials:CERTIFIED REGISTERED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13254 WINDSONG LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-5302
Mailing Address - Country:US
Mailing Address - Phone:301-515-8464
Mailing Address - Fax:
Practice Address - Street 1:13254 WINDSONG LN
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-5302
Practice Address - Country:US
Practice Address - Phone:301-515-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR166136367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD8273022 00Medicaid
MDKBC1CHOtherCAREFIRST BCBS
DCS417-0006OtherCAREFIRST BCBS
MDKBC1CHOtherCAREFIRST BCBS
MD8273022 00Medicaid