Provider Demographics
NPI:1366294175
Name:LOVERTICH, MARY FASER (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:FASER
Last Name:LOVERTICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:FRASER
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-7015
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1200 N STATE ST STE 270
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2027
Practice Address - Country:US
Practice Address - Phone:601-714-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00793363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical