Provider Demographics
NPI:1366810038
Name:WACTOR, AIESHA J (CRNP)
Entity type:Individual
Prefix:
First Name:AIESHA
Middle Name:J
Last Name:WACTOR
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NORTH WOLFE STREET
Mailing Address - Street 2:PHIPPS, SUITE 351
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287
Mailing Address - Country:US
Mailing Address - Phone:410-614-1620
Mailing Address - Fax:410-614-0376
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:CARNEGIE 136
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:443-287-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR216317363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology