Provider Demographics
NPI:1568803856
Name:LOUGH, MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LOUGH
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 1:106 S GILMOR ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223-2425
Mailing Address - Country:US
Mailing Address - Phone:801-362-9856
Mailing Address - Fax:
Practice Address - Street 1:12880 COMMODITY PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3101
Practice Address - Country:US
Practice Address - Phone:813-343-5500
Practice Address - Fax:866-462-7445
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant