Provider Demographics
NPI:1376668269
Name:VINCENT, MARY KOTTKE (MPH, PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KOTTKE
Last Name:VINCENT
Suffix:
Gender:F
Credentials:MPH, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6704 COCKERILLE AVE
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-4730
Mailing Address - Country:US
Mailing Address - Phone:907-957-2535
Mailing Address - Fax:
Practice Address - Street 1:6704 COCKERILLE AVE
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-4730
Practice Address - Country:US
Practice Address - Phone:907-957-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK555363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK8EZ59NMedicare PIN
AK8EC754Medicare PIN
AKP76037Medicare UPIN
AK8EC755Medicare PIN
AK8EZ58NMedicare PIN
AK8EC756Medicare PIN