Provider Demographics
NPI:1427485515
Name:VARDANYAN, LILIT (PA)
Entity type:Individual
Prefix:
First Name:LILIT
Middle Name:
Last Name:VARDANYAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:1110 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1602
Practice Address - Country:US
Practice Address - Phone:443-351-3917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD335033YVZMedicare PIN
MD337104YWV2Medicare PIN
MD335033ZDDBMedicare PIN