Provider Demographics
NPI:1962457580
Name:IRVIN, KATHLEEN E (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:IRVIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:E
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:P.O.B- SUITE G1
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2905
Mailing Address - Country:US
Mailing Address - Phone:410-532-4730
Mailing Address - Fax:410-532-4752
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:P.O.B- SUITE G1
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:410-532-4730
Practice Address - Fax:410-532-4752
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP09784Medicare UPIN