Provider Demographics
NPI:1578742375
Name:ANDERSEN, KATHLEEN (PAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:ANDERSEN
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 1:8186 LARK BROWN RD
Mailing Address - Street 2:STE 201
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6434
Mailing Address - Country:US
Mailing Address - Phone:301-203-2250
Mailing Address - Fax:
Practice Address - Street 1:11711 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5151
Practice Address - Country:US
Practice Address - Phone:301-203-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053150363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical