Provider Demographics
NPI:1063865442
Name:HEBEISEN, KATELYN (PAC)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:HEBEISEN
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 1:120 SISTER PIERRE DR STE 403
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7536
Mailing Address - Country:US
Mailing Address - Phone:410-823-6408
Mailing Address - Fax:
Practice Address - Street 1:120 SISTER PIERRE DR STE 403
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7536
Practice Address - Country:US
Practice Address - Phone:410-823-6408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059007363A00000X
363AM0700X
MDC0006186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0006186OtherMARYLAND BOARD OF HEALTH