Provider Demographics
NPI:1821347592
Name:TATAW, ETA STEPHEN (CRNP)
Entity Type:Individual
Prefix:DR
First Name:ETA
Middle Name:STEPHEN
Last Name:TATAW
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7231 HANOVER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2027
Mailing Address - Country:US
Mailing Address - Phone:301-982-7898
Mailing Address - Fax:301-982-2588
Practice Address - Street 1:7231 HANOVER PKWY STE A
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2027
Practice Address - Country:US
Practice Address - Phone:301-982-7898
Practice Address - Fax:301-982-2588
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR178223363LF0000X
DCRN1011938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD337807100Medicaid
MD424652700Medicaid