Provider Demographics
NPI:1508850751
Name:KUNDERT, HENRIETTA S (PA)
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:S
Last Name:KUNDERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 OLD GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1422
Mailing Address - Country:US
Mailing Address - Phone:301-896-6002
Mailing Address - Fax:301-230-1927
Practice Address - Street 1:8600 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1422
Practice Address - Country:US
Practice Address - Phone:301-896-6002
Practice Address - Fax:301-230-1927
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00B298S47Medicare ID - Type Unspecified
MDP64022Medicare UPIN