Provider Demographics
NPI:1841390713
Name:DEMATTEO PUGH, THERESA L (MS CRNP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:L
Last Name:DEMATTEO PUGH
Suffix:
Gender:F
Credentials:MS CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 WYMAN PARK DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4924 CAMPBELL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-5908
Practice Address - Country:US
Practice Address - Phone:443-442-2300
Practice Address - Fax:443-442-2360
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR076644363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD622361300Medicaid
R13077Medicare UPIN
A095Medicare ID - Type Unspecified