Provider Demographics
NPI:1457331860
Name:NOONAN, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:NOONAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 FAIRY STREET EXT STE A
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1913
Mailing Address - Country:US
Mailing Address - Phone:276-638-5437
Mailing Address - Fax:276-666-6686
Practice Address - Street 1:314 FAIRY STREET EXT STE A
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1913
Practice Address - Country:US
Practice Address - Phone:276-638-5437
Practice Address - Fax:276-666-6686
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000763056C/D/EMedicaid
VA3001601162002Medicaid