Provider Demographics
NPI:1932670122
Name:MANIVASAGAM, MURUGESAN (CRNP)
Entity Type:Individual
Prefix:
First Name:MURUGESAN
Middle Name:
Last Name:MANIVASAGAM
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 SUNNYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-1500
Practice Address - Fax:443-643-1505
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR184344208M00000X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology