Provider Demographics
NPI:1013149798
Name:LINN, MARY A (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:LINN
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 1:620 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-5830
Mailing Address - Country:US
Mailing Address - Phone:479-474-5061
Mailing Address - Fax:479-922-2007
Practice Address - Street 1:620 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-5830
Practice Address - Country:US
Practice Address - Phone:479-474-5061
Practice Address - Fax:479-922-2007
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA383363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200257920AMedicaid
AR179073741Medicaid
OK200257920AMedicaid