Provider Demographics
NPI:1194159277
Name:FULTON, KATHLEEN (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FULTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-9000
Mailing Address - Fax:
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1113389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant