Provider Demographics
NPI:1770560450
Name:HARGROVE, PERCIVAL CARLOS (PA)
Entity type:Individual
Prefix:
First Name:PERCIVAL
Middle Name:CARLOS
Last Name:HARGROVE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13309 WHITAKER PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-5688
Mailing Address - Country:US
Mailing Address - Phone:302-331-7277
Mailing Address - Fax:
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-612-1856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005080363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD467426YWV2Medicare PIN
MD463467YVZMedicare PIN
MD463467ZDDBMedicare PIN