Provider Demographics
NPI:1821285719
Name:YETSO, JULIE K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:K
Last Name:YETSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:M
Other - Last Name:KAPCALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2118 E LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2019
Mailing Address - Country:US
Mailing Address - Phone:410-440-6410
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-5793
Practice Address - Fax:410-328-0248
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00608764Medicare PIN
MDR351Medicare PIN