Provider Demographics
NPI:1184719254
Name:NOWOTNY, KERRI A (PA-C)
Entity type:Individual
Prefix:MS
First Name:KERRI
Middle Name:A
Last Name:NOWOTNY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KERRI
Other - Middle Name:ALISE
Other - Last Name:SEGALOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 944
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:DE
Mailing Address - Zip Code:19956-0944
Mailing Address - Country:US
Mailing Address - Phone:631-513-6955
Mailing Address - Fax:
Practice Address - Street 1:525 GLENBURN AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1414
Practice Address - Country:US
Practice Address - Phone:410-221-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q37282Medicare UPIN