Provider Demographics
NPI:1669731154
Name:PURTLE, MARY KATHERINE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:PURTLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:DUNKLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-231-8772
Mailing Address - Fax:717-231-8435
Practice Address - Street 1:4300 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109
Practice Address - Country:US
Practice Address - Phone:717-231-8772
Practice Address - Fax:717-231-8435
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055544363A00000X, 208M00000X, 363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103144123Medicaid