Provider Demographics
NPI:1518264761
Name:MCCOY, MARY MARGARET (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:MCCOY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 VINCENT AVE
Mailing Address - Street 2:BASEMENT
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1763
Mailing Address - Country:US
Mailing Address - Phone:608-921-4359
Mailing Address - Fax:
Practice Address - Street 1:1825 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:718-904-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant