Provider Demographics
NPI:1578589453
Name:MANKEY, MARY THERESE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESE
Last Name:MANKEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:THERESA
Other - Last Name:KURUDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3337 BRITTON RD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:MI
Mailing Address - Zip Code:48872-9706
Mailing Address - Country:US
Mailing Address - Phone:517-625-3004
Mailing Address - Fax:517-625-5001
Practice Address - Street 1:3337 BRITTON RD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:MI
Practice Address - Zip Code:48872-9706
Practice Address - Country:US
Practice Address - Phone:517-625-3004
Practice Address - Fax:517-625-5001
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1578589453Medicaid
MIM02890 P09Medicare PIN
MIP71788Medicare UPIN