Provider Demographics
NPI:1720483555
Name:DIFABRIZIO, THERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DIFABRIZIO
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 1:739 S LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3853
Mailing Address - Country:US
Mailing Address - Phone:760-419-4413
Mailing Address - Fax:
Practice Address - Street 1:1701 TWIN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227-3553
Practice Address - Country:US
Practice Address - Phone:410-737-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51688363A00000X
MDC0006812363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant