Provider Demographics
NPI:1245800937
Name:MURRAY, MALLORY JANE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MALLORY
Middle Name:JANE
Last Name:MURRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8877 MERCER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-2300
Mailing Address - Country:US
Mailing Address - Phone:231-675-7250
Mailing Address - Fax:
Practice Address - Street 1:8877 MERCER RD
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-2300
Practice Address - Country:US
Practice Address - Phone:231-675-7250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant