Provider Demographics
NPI:1851800353
Name:VONDER HAAR, MARY LELA VALENTINE (PA)
Entity Type:Individual
Prefix:
First Name:MARY LELA
Middle Name:VALENTINE
Last Name:VONDER HAAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LELA
Other - Last Name:VALENTINE
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 JACKSON AVE W
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5409
Mailing Address - Country:US
Mailing Address - Phone:662-380-5560
Mailing Address - Fax:
Practice Address - Street 1:2222 JACKSON AVE W
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5409
Practice Address - Country:US
Practice Address - Phone:662-380-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12044363A00000X
MSPA00685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant