Provider Demographics
NPI:1649920216
Name:ESUZOR, GIDEON
Entity type:Individual
Prefix:
First Name:GIDEON
Middle Name:
Last Name:ESUZOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13603 WHITE BARN LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3341
Mailing Address - Country:US
Mailing Address - Phone:404-788-2882
Mailing Address - Fax:
Practice Address - Street 1:10450 SHAKER DR STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2348
Practice Address - Country:US
Practice Address - Phone:410-800-8179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-26
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN190476163WP0809X
VA0024189217363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health