Provider Demographics
NPI:1659795383
Name:ANDERSON, MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-226-5018
Mailing Address - Fax:419-998-4514
Practice Address - Street 1:1003 BELLEFONTAINE AVE STE 100
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1868
Practice Address - Country:US
Practice Address - Phone:419-998-8234
Practice Address - Fax:419-998-8233
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003998363A00000X
OH50.003998RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0100075Medicaid