Provider Demographics
NPI:1336599083
Name:ISOM, MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ISOM
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 1:1366 17TH AVE N
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-3139
Mailing Address - Country:US
Mailing Address - Phone:701-260-9034
Mailing Address - Fax:
Practice Address - Street 1:332 2ND AVE N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4528
Practice Address - Country:US
Practice Address - Phone:701-642-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant