Provider Demographics
NPI:1023055498
Name:TENALI, EDWIN N (PA)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:N
Last Name:TENALI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-2882
Mailing Address - Fax:410-328-2977
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-2882
Practice Address - Fax:410-328-2977
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD180254Y1PMedicare PIN
MDQ69919Medicare UPIN