Provider Demographics
NPI:1790725638
Name:MCNALLY, MARTHA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:MCNALLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:KERNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:324 GANNETT DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3270
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAP115202Medicare PIN