Provider Demographics
NPI:1669709853
Name:GADAM, PRAVEENA (PA-C)
Entity type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:
Last Name:GADAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6730 HOLABIRD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222-1700
Mailing Address - Country:US
Mailing Address - Phone:410-288-6226
Mailing Address - Fax:410-288-9048
Practice Address - Street 1:6730 HOLABIRD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-1700
Practice Address - Country:US
Practice Address - Phone:410-288-6226
Practice Address - Fax:410-288-9048
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant