Provider Demographics
NPI:1114033370
Name:MOTT, MARY J (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:MOTT
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8923 MANOR LOOP APT 105
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-3826
Mailing Address - Country:US
Mailing Address - Phone:419-305-3190
Mailing Address - Fax:
Practice Address - Street 1:3920 BEE RIDGE RD
Practice Address - Street 2:BLDG E STE F
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1207
Practice Address - Country:US
Practice Address - Phone:941-926-2270
Practice Address - Fax:941-926-3948
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101315363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292028000Medicaid
FLPA9101315OtherPHYS ASST LICENSE
FLPA9101315OtherPHYS ASST LICENSE