Provider Demographics
NPI:1790767705
Name:TOLBERT, MARY SUSAN SHAW (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY SUSAN
Middle Name:SHAW
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1511 DONELSON PKWY
Mailing Address - Street 2:WOMACK ARMY MEDICAL CENTER
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-3749
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:BUILDING C-1722
Practice Address - Street 2:TAGATAY AND GRUBER RD.
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-8282
Practice Address - Fax:910-907-9360
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001709363A00000X
NC102610363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7044670Medicaid
WA7044670Medicaid
WAS43811Medicare UPIN