Provider Demographics
NPI:1609273218
Name:JOSEPH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOSEPH
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 1:527 MEDICAL PARK DR
Mailing Address - Street 2:STE 401
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:724-564-4690
Mailing Address - Fax:
Practice Address - Street 1:2160 SPRINGHILL FURNACE RD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:PA
Practice Address - Zip Code:15478-1428
Practice Address - Country:US
Practice Address - Phone:724-564-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057301363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical