Provider Demographics
NPI:1447231667
Name:HENRY, MARY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:HENRY
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:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-213-6121
Mailing Address - Fax:928-774-6687
Practice Address - Street 1:2109 NAVAJO BLVD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-0000
Practice Address - Country:US
Practice Address - Phone:928-524-2851
Practice Address - Fax:928-524-2171
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ446452Medicaid
AZ446452Medicaid