Provider Demographics
NPI:1457389496
Name:BROWN, MARY G (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:G
Other - Last Name:BRENYO BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1431 CENTERPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE STE B101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-6514
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:859-323-6411
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA642363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002408Medicaid
KY0647615Medicare ID - Type UnspecifiedMKY
KY95002408Medicaid
P36266Medicare UPIN
KY0975623Medicare PIN
KY0647615Medicare PIN