Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | MD060329-L | PA |
NPI | 1285636035 |
---|---|
Provider Name | Evangeline Grover |
First Address | Fort Washington, PA 19034-2405 |
Second Address | Fort Washington, PA 19034-2405 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2005 |
Last Update Date | 21/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BG5379335 | DEA (01) | PA |
G57326 | (02) | PA |
MD060329-L | MEDICAL LICENSE (01) | PA |