Provider Demographics
NPI:1043445380
Name:HAMILTON, MARY BOLAND (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BOLAND
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ASHLEY
Other - Last Name:BOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:80 HUMPHREYS SUITE 230
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:US
Mailing Address - Phone:901-259-2440
Mailing Address - Fax:225-767-6721
Practice Address - Street 1:80 HUMPHREYS SUITE 230
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117
Practice Address - Country:US
Practice Address - Phone:901-259-2440
Practice Address - Fax:225-767-6721
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA657Other710916908