Provider Demographics
NPI:1760485932
Name:HART, MARY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W WILLIAM CANNON DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5253
Mailing Address - Country:US
Mailing Address - Phone:512-416-7246
Mailing Address - Fax:512-275-2833
Practice Address - Street 1:3201 S AUSTIN AVE
Practice Address - Street 2:SUITE 265
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7545
Practice Address - Country:US
Practice Address - Phone:512-416-7246
Practice Address - Fax:512-275-2833
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03126363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194811901Medicaid
TX194811902Medicaid
TX8C0168Medicare PIN
TX194811902Medicaid
TX194811901Medicaid