Provider Demographics
NPI:1770912313
Name:EVERHART, MARY NICOLE (PA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:NICOLE
Last Name:EVERHART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-2709
Mailing Address - Country:US
Mailing Address - Phone:512-978-8400
Mailing Address - Fax:512-901-9726
Practice Address - Street 1:1705 E 11TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702
Practice Address - Country:US
Practice Address - Phone:512-978-8400
Practice Address - Fax:512-901-9726
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11896363AM0700X, 363A00000X
FLPA9107501363AM0700X, 363AS0400X
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
FLPA9107501OtherMEDICAL LICENSE
FL010608200Medicaid
FLHS092ZMedicare PIN