Provider Demographics
NPI:1902134828
Name:BROCK, ANITA (PAC)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 FARMINGTON ROAD WEST
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607
Mailing Address - Country:US
Mailing Address - Phone:571-269-1509
Mailing Address - Fax:
Practice Address - Street 1:207 FARMINGTON ROAD WEST
Practice Address - Street 2:
Practice Address - City:ACCOKEEK
Practice Address - State:MD
Practice Address - Zip Code:20607
Practice Address - Country:US
Practice Address - Phone:571-269-1509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030636363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCPA030636OtherPAC LICENSE