Provider Demographics
NPI:1033590724
Name:GW THE MEDICAL FACULTY ASSOCIATE
Entity type:Organization
Organization Name:GW THE MEDICAL FACULTY ASSOCIATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:MAGBOO
Authorized Official - Last Name:BRUCAL
Authorized Official - Suffix:
Authorized Official - Credentials:AGPCNP-BC
Authorized Official - Phone:240-481-3356
Mailing Address - Street 1:10401 GROSVENOR PL
Mailing Address - Street 2:APT 1311
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4646
Mailing Address - Country:US
Mailing Address - Phone:240-481-3356
Mailing Address - Fax:
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:DEPARTMENT OF SURGERY, SUITE 6B-412
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-741-3225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1004515363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty