Provider Demographics
NPI:1578287934
Name:UDOSEN, MKPOUTO N (PA)
Entity Type:Individual
Prefix:
First Name:MKPOUTO
Middle Name:N
Last Name:UDOSEN
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 1:463 SHORE ACRES RD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-1920
Mailing Address - Country:US
Mailing Address - Phone:931-502-9455
Mailing Address - Fax:
Practice Address - Street 1:520 W FAYETTE ST STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1756
Practice Address - Country:US
Practice Address - Phone:931-502-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant