Provider Demographics
NPI:1407879042
Name:JONES, MARY GWENDOLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GWENDOLYN
Last Name:JONES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2600 SW HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3505
Mailing Address - Country:US
Mailing Address - Phone:206-300-3294
Mailing Address - Fax:
Practice Address - Street 1:2600 SW HOLDEN ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3505
Practice Address - Country:US
Practice Address - Phone:206-300-3294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004952363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7060890Medicaid
WAQ71869Medicare UPIN
G8867105Medicare PIN