Provider Demographics
NPI:1003927088
Name:MCGOURTY, MARY K (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:MCGOURTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3677
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-3677
Mailing Address - Country:US
Mailing Address - Phone:603-577-7900
Mailing Address - Fax:603-577-7972
Practice Address - Street 1:68 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEPPERELL
Practice Address - State:MA
Practice Address - Zip Code:01463-1560
Practice Address - Country:US
Practice Address - Phone:978-433-6317
Practice Address - Fax:978-433-0567
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1179OtherBLUE CROSS BLUE SHIELD
MANP1179OtherBLUE CROSS BLUE SHIELD