Provider Demographics
NPI:1124416508
Name:BURNELL, MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BURNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 E MILL PLAIN BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2092
Mailing Address - Country:US
Mailing Address - Phone:541-728-1019
Mailing Address - Fax:360-254-6089
Practice Address - Street 1:9135 SW BARNES RD STE 875
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6683
Practice Address - Country:US
Practice Address - Phone:503-297-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA170904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant