Provider Demographics
NPI:1114928637
Name:DOUGLAS, MARY KATHRYN (PAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 N US 31 S
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4533
Mailing Address - Country:US
Mailing Address - Phone:231-929-1234
Mailing Address - Fax:231-935-0984
Practice Address - Street 1:3074 N US 31 S
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4533
Practice Address - Country:US
Practice Address - Phone:231-929-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMD003850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N30860Medicare PIN