Provider Demographics
NPI:1558970558
Name:MRIDHA, IMRAN AHMED (PA)
Entity Type:Individual
Prefix:
First Name:IMRAN
Middle Name:AHMED
Last Name:MRIDHA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, STE. 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-7958
Mailing Address - Country:US
Mailing Address - Phone:703-914-8000
Mailing Address - Fax:
Practice Address - Street 1:75 KINGS HIGHWAY CUTOFF STE 3A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5340
Practice Address - Country:US
Practice Address - Phone:203-743-7264
Practice Address - Fax:203-792-3920
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant