Healthcare Provider Details

I. General information

NPI: 1174810600
Provider Name (Legal Business Name): ELISE KATRINA DZINTARS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E UNIVERSITY PKWY
BALTIMORE MD
21218-2829
US

IV. Provider business mailing address

3549 ROLAND AVE APT 202
BALTIMORE MD
21211-2432
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-2000
  • Fax:
Mailing address:
  • Phone: 503-730-3623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0004510
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: