Provider Demographics
NPI:1174964183
Name:KANNARKAT, ANNIE VINCENT (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:VINCENT
Last Name:KANNARKAT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S CHARLES ST STE 150
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-2730
Mailing Address - Country:US
Mailing Address - Phone:410-752-3010
Mailing Address - Fax:
Practice Address - Street 1:100 S CHARLES ST STE 150
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-2730
Practice Address - Country:US
Practice Address - Phone:410-752-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7527363A00000X
MDC06483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC06483OtherMD PHYSICIAN ASSISTANT LICENSE
GA7527OtherGA PHYSICIAN ASSISTANT LICENSE