Provider Demographics
NPI:1255840385
Name:ST. JOHN, MARY (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2015 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-5328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 SCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6046
Practice Address - Country:US
Practice Address - Phone:704-334-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07443363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical