Provider Demographics
NPI:1124123336
Name:KLEKNER, KEVIN (PA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:KLEKNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:
Practice Address - Street 1:7601 OSLER DR
Practice Address - Street 2:SUITE 506
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7700
Practice Address - Country:US
Practice Address - Phone:410-581-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00430363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS69481Medicare UPIN
MD606YMedicare ID - Type Unspecified