=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104228568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY KATE HEATON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2014
-----------------------------------------------------
Last Update Date | 04/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5401 OLD COURT RD
-----------------------------------------------------
City | RANDALLSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21133-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-521-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4380 DONCASTER DR
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21043-6782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-220-7546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | C05554
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------