Provider Demographics
NPI:1821635749
Name:EJERENWA, COLMAN (NP)
Entity Type:Individual
Prefix:MR
First Name:COLMAN
Middle Name:
Last Name:EJERENWA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 PALMERSTON CT
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1967
Mailing Address - Country:US
Mailing Address - Phone:301-536-0044
Mailing Address - Fax:
Practice Address - Street 1:8136 LIBERTY RD STE C
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-3021
Practice Address - Country:US
Practice Address - Phone:301-536-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR197772363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty