Provider Demographics
NPI:1104253939
Name:ECKART, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ECKART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363W SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-5327
Mailing Address - Country:US
Mailing Address - Phone:907-376-2411
Mailing Address - Fax:907-352-3363
Practice Address - Street 1:561 S DENALI ST
Practice Address - Street 2:SUITE E
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6439
Practice Address - Country:US
Practice Address - Phone:907-745-7944
Practice Address - Fax:907-745-7918
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant