Provider Demographics
NPI:1811996291
Name:JEROSIMICH, CAROL A (PA-C)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:JEROSIMICH
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 1:170 JENNIFER RD
Mailing Address - Street 2:STE 240
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7995
Mailing Address - Country:US
Mailing Address - Phone:410-571-9000
Mailing Address - Fax:410-266-1507
Practice Address - Street 1:170 JENNIFER RD STE 240
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7995
Practice Address - Country:US
Practice Address - Phone:410-571-9000
Practice Address - Fax:410-266-1507
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001915363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
487760200OtherFEDERAL WORKMANS COMP
016634M21Medicare PIN
P00289589Medicare PIN
577MK473Medicare PIN