Provider Demographics
NPI:1295791960
Name:MCNICHOLAS, MARY C (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:MCNICHOLAS
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 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 920
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2655
Mailing Address - Fax:510-879-9071
Practice Address - Street 1:2100 POWELL ST
Practice Address - Street 2:SUITE 920
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1826
Practice Address - Country:US
Practice Address - Phone:510-350-2655
Practice Address - Fax:510-879-9071
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14376363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14376Medicaid
CAP92390Medicare UPIN
CA00PA143760Medicare ID - Type UnspecifiedMEDICARE NUMBER