Provider Demographics
NPI:1275626384
Name:WARDLAW, MARY E (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WARDLAW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:GAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1103
Mailing Address - Country:US
Mailing Address - Phone:510-204-8130
Mailing Address - Fax:510-524-0861
Practice Address - Street 1:500 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1103
Practice Address - Country:US
Practice Address - Phone:510-204-8130
Practice Address - Fax:510-524-0861
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7899363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner