Provider Demographics
NPI:1780228197
Name:BARTH, JEREMY M (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:BARTH
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 1:5886 MORNINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3508
Mailing Address - Country:US
Mailing Address - Phone:240-893-1735
Mailing Address - Fax:
Practice Address - Street 1:5886 MORNINGBIRD LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3508
Practice Address - Country:US
Practice Address - Phone:240-893-1735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant