=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932235124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATIE S. WALTON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2007
-----------------------------------------------------
Last Update Date | 12/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5401 OLD COURT ROAD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-496-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4081 FRAGILE SAIL WAY
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21042-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-740-6102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | C0003355
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------