Provider Demographics
NPI:1518926500
Name:NI, NAN (MD)
Entity Type:Individual
Prefix:DR
First Name:NAN
Middle Name:
Last Name:NI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 RED FOX CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-5721
Mailing Address - Country:US
Mailing Address - Phone:410-465-5820
Mailing Address - Fax:410-261-8021
Practice Address - Street 1:200 E 33RD ST STE 471
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3322
Practice Address - Country:US
Practice Address - Phone:410-261-8019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056254207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD905900800Medicaid
MD666M178FMedicare PIN
MD905900800Medicaid