Provider Demographics
NPI:1134126824
Name:GRACE, MARY CATHERINE (PA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHERINE
Last Name:GRACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:2455 NE LOOP 410
Mailing Address - Street 2:STE 100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5649
Mailing Address - Country:US
Mailing Address - Phone:210-599-6000
Mailing Address - Fax:210-657-5586
Practice Address - Street 1:1900 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3942
Practice Address - Country:US
Practice Address - Phone:210-226-3204
Practice Address - Fax:210-226-2854
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA00293363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB159554OtherWELLMED MEDICAL GROUP PA
TX312816701OtherWELLMED MEDICAID