Provider Demographics
NPI:1235612649
Name:HERBERT, MARY (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HERBERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:
Other - Last Name:HERBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:201 MILLSPRING DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2328
Mailing Address - Country:US
Mailing Address - Phone:434-426-1854
Mailing Address - Fax:
Practice Address - Street 1:119 TRADEWYND DR STE A
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-5288
Practice Address - Country:US
Practice Address - Phone:434-237-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical