Provider Demographics
NPI:1659049526
Name:ECKENRODE, ERNEST GREGORY IV (PA-C)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:GREGORY
Last Name:ECKENRODE
Suffix:IV
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4940 BUCKS SCHOOL HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3321
Mailing Address - Country:US
Mailing Address - Phone:410-458-2420
Mailing Address - Fax:
Practice Address - Street 1:10153 YORK RD
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-3398
Practice Address - Country:US
Practice Address - Phone:410-472-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant