Provider Demographics
NPI:1598826174
Name:MATHERLY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MATHERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 S VAL VISTA DR
Mailing Address - Street 2:#2093
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1066 N POWER RD
Practice Address - Street 2:STE. 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5709
Practice Address - Country:US
Practice Address - Phone:480-353-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant