Provider Demographics
NPI:1932685948
Name:CONDON, STEPHEN (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:CONDON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 DEFENSE HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-8902
Mailing Address - Country:US
Mailing Address - Phone:667-204-7000
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:15500 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-3001
Practice Address - Country:US
Practice Address - Phone:443-481-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPENDING225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant