Provider Demographics
NPI:1942220207
Name:DORE, MARY GRAHAM (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRAHAM
Last Name:DORE
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 1:4525 CAMERON VALLEY PARKWAY
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:704-512-6240
Mailing Address - Fax:
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:SUITE 1500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4369
Practice Address - Country:US
Practice Address - Phone:704-512-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102721Medicaid
NC2757508CMedicare ID - Type UnspecifiedPART B
NC8102721Medicaid
NCNC4285LMedicare PIN
NCNC4285PMedicare PIN
NCNC4285CMedicare PIN
NCNC4285EMedicare PIN
NCNC4285GMedicare PIN
NCNC4285JMedicare PIN
NCNC4285KMedicare PIN
NCNC4285MMedicare PIN
NCNC4285HMedicare PIN
NCNC4285BMedicare PIN
NCNC4285NMedicare PIN
NCNC4285IMedicare PIN