Provider Demographics
NPI:1710949003
Name:WASKOW, LARRY A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:A
Last Name:WASKOW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:410-581-1600
Mailing Address - Fax:
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:SUITE 460
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
Practice Address - Country:US
Practice Address - Phone:410-581-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD970005850OtherR/R MEDICARE PROVIDER #
MD970005850OtherR/R MEDICARE PROVIDER #
MDS59796Medicare UPIN
MDKL19E923Medicare PIN
MDKL09E922Medicare PIN
MDKL33E921Medicare PIN