Healthcare Provider Details

I. General information

NPI: 1699212266
Provider Name (Legal Business Name): KANTA DUTTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 FRANKLIN SQUARE DR
BALTIMORE MD
21237-3901
US

IV. Provider business mailing address

8609 STARK CT
NOTTINGHAM MD
21236-5505
US

V. Phone/Fax

Practice location:
  • Phone: 443-777-7123
  • Fax:
Mailing address:
  • Phone: 718-406-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006352
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: