Provider Demographics
NPI:1154638260
Name:KISTLER, MARY ELLEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:KISTLER
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1 MONTVALE AVE
Mailing Address - Street 2:STE 502
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3559
Mailing Address - Country:US
Mailing Address - Phone:781-279-0971
Mailing Address - Fax:617-573-5646
Practice Address - Street 1:1 MONTVALE AVE
Practice Address - Street 2:STE 502
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3559
Practice Address - Country:US
Practice Address - Phone:781-279-0971
Practice Address - Fax:617-573-5646
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2014-01-02
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Provider Licenses
StateLicense IDTaxonomies
SC1545363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical