Glenda Prudencio, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

C05930 Issued in MD

Practice address

12150 Annapolis Rd Ste 308
Glenn Dale, MD 20769-9183

Phone

(301) 805-0006

NPI assigned

Aug 30, 2015

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in DC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Privia Medical Group, LLC

  • Internal Medicine Physician
  • Arlington, VA
  • NPI 1013042480

  DC

  Medicare reassignment NPD
• Privia Medical Group, LLC

  • Pain Medicine (Psychiatry & Neurology) Physician
  • Rockville, MD
  • NPI 1811715436
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1440892800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1568937600000",
    "number": "1902273584",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1440 CHANNING ST NE",
            "city": "WASHINGTON",
            "state": "DC",
            "postal_code": "200182004",
            "telephone_number": "301-412-3702"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12150 ANNAPOLIS RD STE 308",
            "city": "GLENN DALE",
            "state": "MD",
            "postal_code": "207699183",
            "telephone_number": "301-805-0006"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "14300 Gallant Fox Ln",
            "address_2": "Suite 118",
            "address_purpose": "LOCATION",
            "city": "Bowie",
            "state": "MD",
            "postal_code": "207154003",
            "country_code": "US",
            "telephone_number": "301-805-4348",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PRUDENCIO",
        "first_name": "GLENDA",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-08-30",
        "last_updated": "2019-09-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "VA",
            "license": "0110-005091",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "MD",
            "license": "C05930",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Privia Medical Group, LLC
• Privia Medical Group, LLC
• Privia Medical Group, LLC
• Proactive Healthcare Services LLC
• Proactive Healthcare Services LLC
• Jessica Pryor, PA-C
• Quantum Rehabilitation Medicine
• Ketki Ajit Raktavan, MPT
• Donald Reese
• Rehabit Smartcenter, LLC

• Medical Physician Assistant in Glenn Dale, MD
• Providers in Glenn Dale, MD by specialty
• Medical Physician Assistant in Maryland

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.