Provider Demographics
NPI:1215993811
Name:MCENELLY, MARY (PA C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:MCENELLY
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Gender:F
Credentials:PA C
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Mailing Address - Street 1:120 LABREE AVENUE SOUTH
Mailing Address - Street 2:NORTHWEST MEDICAL CENTER MENTAL HEALTH DIVISION
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701
Mailing Address - Country:US
Mailing Address - Phone:218-683-4351
Mailing Address - Fax:218-683-4362
Practice Address - Street 1:120 LABREE AVENUE SOUTH
Practice Address - Street 2:NORTHWEST MEDICAL CENTER MENTAL HEALTH DIVISION
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701
Practice Address - Country:US
Practice Address - Phone:218-683-4351
Practice Address - Fax:218-683-4362
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN9315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S51406Medicare UPIN