Provider Demographics
NPI:1407858053
Name:STAMPER, GWEN D (DSC PT)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:D
Last Name:STAMPER
Suffix:
Gender:F
Credentials:DSC PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S FREDERICK AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-4151
Mailing Address - Country:US
Mailing Address - Phone:301-963-3639
Mailing Address - Fax:
Practice Address - Street 1:800 S FREDERICK AVE STE 110
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-4151
Practice Address - Country:US
Practice Address - Phone:301-208-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR22897Medicare UPIN
MDG01816S01Medicare PIN