Provider Demographics
NPI:1841201654
Name:TAKAISHI, MARY C (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:TAKAISHI
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 1:914 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-5040
Mailing Address - Country:US
Mailing Address - Phone:785-764-9140
Mailing Address - Fax:
Practice Address - Street 1:511 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:KS
Practice Address - Zip Code:67410-2153
Practice Address - Country:US
Practice Address - Phone:785-263-6661
Practice Address - Fax:785-263-6633
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST00779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant