Provider Demographics
NPI:1922605583
Name:MOULTON, KURT WILLIAM (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:WILLIAM
Last Name:MOULTON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WASHINGTON AVE APT 1712
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4735
Mailing Address - Country:US
Mailing Address - Phone:563-940-5380
Mailing Address - Fax:
Practice Address - Street 1:HEALTH CENTER AT WARD AND WEST 8000 YORK RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21252-0001
Practice Address - Country:US
Practice Address - Phone:410-704-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant