Provider Demographics
NPI:1619109766
Name:BOONE, MARY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELIZABETH
Last Name:BOONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:12006 KILARNEY DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7207
Mailing Address - Country:US
Mailing Address - Phone:540-786-9771
Mailing Address - Fax:540-548-8803
Practice Address - Street 1:12006 KILARNEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-7207
Practice Address - Country:US
Practice Address - Phone:540-786-9771
Practice Address - Fax:540-548-8803
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA020985C58Medicare PIN