Provider Demographics
NPI:1922033851
Name:HEWETT, MARY L (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:HEWETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751137
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1137
Mailing Address - Country:US
Mailing Address - Phone:866-448-1641
Mailing Address - Fax:
Practice Address - Street 1:2233 NORTHWOODS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4007
Practice Address - Country:US
Practice Address - Phone:866-448-1641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA254363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0024PAMedicaid
S56577Medicare UPIN