Provider Demographics
NPI:1972238178
Name:PAVELOVA, MIROSLAVA
Entity type:Individual
Prefix:
First Name:MIROSLAVA
Middle Name:
Last Name:PAVELOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12112 OTIS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2218
Mailing Address - Country:US
Mailing Address - Phone:240-899-0827
Mailing Address - Fax:
Practice Address - Street 1:7678 QUARTERFIELD RD STE 201
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-7071
Practice Address - Country:US
Practice Address - Phone:410-766-9413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR222459363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care