Healthcare Provider Details

I. General information

NPI: 1174964183
Provider Name (Legal Business Name): ANNIE VINCENT KANNARKAT PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S CHARLES ST STE 150
BALTIMORE MD
21201-2730
US

IV. Provider business mailing address

100 S CHARLES ST STE 150
BALTIMORE MD
21201-2730
US

V. Phone/Fax

Practice location:
  • Phone: 410-752-3010
  • Fax:
Mailing address:
  • Phone: 410-752-3010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7527
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC06483
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: