Provider Demographics
NPI:1265686950
Name:ELAM, MARY JO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:ELAM
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 1:2941 SIERRA CT SW
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-8503
Mailing Address - Country:US
Mailing Address - Phone:319-337-7642
Mailing Address - Fax:
Practice Address - Street 1:201 S CLINTON ST
Practice Address - Street 2:#195
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4034
Practice Address - Country:US
Practice Address - Phone:319-384-0520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IA001965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAMEMBERP00737311OtherRAILROAD MEDICARE