1609923507 NPI number — PATRICIA MUTHAURA MD

Table of content: PATRICIA MUTHAURA MD (NPI 1609923507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609923507 NPI number — PATRICIA MUTHAURA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUTHAURA
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609923507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
344 GLENN ROSE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-1784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-220-4585
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
919 CONESTOGA RD
Provider Second Line Business Practice Location Address:
BLDG#1, SUITE 104
Provider Business Practice Location Address City Name:
BRYN MAWR
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19010-1352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-525-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X , with the licence number:  MD423543 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MD0423543I . This is a "MEDICAL LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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