Provider Demographics
NPI:1023025384
Name:ENGLE, MARY A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:ENGLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:FLANNERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:47 FIELDS LN
Mailing Address - Street 2:
Mailing Address - City:BUSY
Mailing Address - State:KY
Mailing Address - Zip Code:41723-8849
Mailing Address - Country:US
Mailing Address - Phone:606-487-0868
Mailing Address - Fax:
Practice Address - Street 1:271 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1939
Practice Address - Country:US
Practice Address - Phone:606-439-1316
Practice Address - Fax:606-435-0752
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004792Medicaid
KYQ19885Medicare UPIN
KY95004792Medicaid