Provider Demographics
NPI:1619625233
Name:DUFFY, MARY K (AA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:DUFFY
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36500 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4899
Mailing Address - Country:US
Mailing Address - Phone:262-434-1000
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI205-017367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant