Provider Demographics
NPI:1205185261
Name:PICKARD, MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PICKARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:407 S SCHWARTZ AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5925
Practice Address - Country:US
Practice Address - Phone:505-609-6770
Practice Address - Fax:505-609-6775
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2017-07-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2012-0034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant