Provider Demographics
NPI:1124769757
Name:MUNDT, MARTA (PAC)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:MUNDT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11915 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2065
Mailing Address - Country:US
Mailing Address - Phone:240-354-1307
Mailing Address - Fax:
Practice Address - Street 1:11915 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902-2065
Practice Address - Country:US
Practice Address - Phone:855-910-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009674363A00000X
VA0110010586363A00000X
PAOA006015363A00000X
PAMA063362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant