Provider Demographics
NPI:1124038724
Name:MICHENER, MARY S (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:MICHENER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:859 MANKATO AVENUE
Mailing Address - Street 2:WINONA CLINIC LTD
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987
Mailing Address - Country:US
Mailing Address - Phone:507-454-3680
Mailing Address - Fax:507-457-7672
Practice Address - Street 1:859 MANKATO AVENUE
Practice Address - Street 2:WINONA CLINIC LTD
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-454-3680
Practice Address - Fax:507-457-7672
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-12-13
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Provider Licenses
StateLicense IDTaxonomies
MN38452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN636227300Medicaid
MN636227300Medicaid
MN080003765Medicare ID - Type Unspecified