Provider Demographics
NPI:1053148965
Name:RUSZALA, NICHOLAS BRADLEY
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BRADLEY
Last Name:RUSZALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6830 HOSPITAL DR STE 206
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-4377
Mailing Address - Country:US
Mailing Address - Phone:410-238-5390
Mailing Address - Fax:
Practice Address - Street 1:6830 HOSPITAL DR STE 206
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-4377
Practice Address - Country:US
Practice Address - Phone:410-238-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009970363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant