Provider Demographics
NPI:1225696800
Name:ABRAHAM, MARY KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:715 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 S 9TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4911
Practice Address - Country:US
Practice Address - Phone:719-269-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0005758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant