Provider Demographics
NPI:1720020217
Name:TUTHILL, MARY ANN (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:TUTHILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6533 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8737
Practice Address - Country:US
Practice Address - Phone:208-367-4170
Practice Address - Fax:208-367-8135
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-13363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001493100Medicaid
ID001493100Medicaid
ID1665612Medicare ID - Type Unspecified