Healthcare Provider Details

I. General information

NPI: 1962457580
Provider Name (Legal Business Name): KATHLEEN E. IRVIN P.A-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN E. SHEA P.A-C

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SAINT PAUL ST
BALTIMORE MD
21202-2165
US

IV. Provider business mailing address

5601 LOCH RAVEN BLVD P.O.B- SUITE G1
BALTIMORE MD
21239-2905
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9000
  • Fax:
Mailing address:
  • Phone: 410-532-4730
  • Fax: 410-532-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003018
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: