Provider Demographics
NPI:1548219793
Name:MCINTYRE, KEITH R (CRNP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:MCINTYRE
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64474
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4474
Mailing Address - Country:US
Mailing Address - Phone:410-933-7400
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4515
Practice Address - Country:US
Practice Address - Phone:410-583-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR086452363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD356803200Medicaid
MDKR52812YMedicare PIN
MDS86116Medicare UPIN
MD356803200Medicaid