Provider Demographics
NPI:1942577184
Name:BLOCKER, MARY BETH (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BLOCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14703 AVERY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-3605
Mailing Address - Country:US
Mailing Address - Phone:301-762-5613
Mailing Address - Fax:301-762-3451
Practice Address - Street 1:14703 AVERY RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20853-3605
Practice Address - Country:US
Practice Address - Phone:301-762-5613
Practice Address - Fax:301-762-3451
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0000903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant