Provider Demographics
NPI:1881202570
Name:VARGHESE, JISHA S (A-GNP-C)
Entity Type:Individual
Prefix:
First Name:JISHA
Middle Name:S
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3257 RAMBLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2445
Mailing Address - Country:US
Mailing Address - Phone:443-518-9907
Mailing Address - Fax:
Practice Address - Street 1:3257 RAMBLEWOOD RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2445
Practice Address - Country:US
Practice Address - Phone:443-518-9907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-19
Last Update Date:2020-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR160402363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health