Provider Demographics
NPI:1689650871
Name:MULLEN, KATHRYN L (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:MULLEN
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 1:3500 BOSTON ST STE J1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5723
Mailing Address - Country:US
Mailing Address - Phone:410-522-0001
Mailing Address - Fax:410-522-0017
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5803
Practice Address - Country:US
Practice Address - Phone:410-787-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA30076363A00000X
MDC0002127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S87804Medicare UPIN
MDK727L061Medicare PIN
DC014702N64Medicare ID - Type Unspecified