Provider Demographics
NPI:1225817851
Name:CORREIA, JONATHAN ADAM
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ADAM
Last Name:CORREIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9658 BALTIMORE AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1358
Mailing Address - Country:US
Mailing Address - Phone:301-220-1930
Mailing Address - Fax:301-220-1906
Practice Address - Street 1:9658 BALTIMORE AVE STE 420
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1358
Practice Address - Country:US
Practice Address - Phone:301-220-1930
Practice Address - Fax:301-220-1906
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR246603363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care