Provider Demographics
NPI:1336219252
Name:EANES, MARY F (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:EANES
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 1:9700 EL CAMOINO REAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5571
Mailing Address - Country:US
Mailing Address - Phone:805-461-9000
Mailing Address - Fax:805-461-9001
Practice Address - Street 1:9700 EL CAMINO REAL
Practice Address - Street 2:SUITE 100
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5569
Practice Address - Country:US
Practice Address - Phone:805-461-9000
Practice Address - Fax:805-461-9001
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 12590363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 12590OtherMEDICAL LICENSE #