Provider Demographics
NPI:1679874218
Name:PHUL, TANJA
Entity type:Individual
Prefix:
First Name:TANJA
Middle Name:
Last Name:PHUL
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 1:312 BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-2412
Mailing Address - Country:US
Mailing Address - Phone:443-949-8065
Mailing Address - Fax:
Practice Address - Street 1:312 BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-2412
Practice Address - Country:US
Practice Address - Phone:443-949-8065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-13
Last Update Date:2010-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01826171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD27-3950314OtherFEDERAL TAX ID NUMBER