Provider Demographics
NPI:1487347456
Name:HOOVER, MARY PATRICIA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:HOOVER
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 1:4790 CENTERVILLE RD APT 215
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55127-2319
Mailing Address - Country:US
Mailing Address - Phone:612-840-8840
Mailing Address - Fax:
Practice Address - Street 1:22439 EVERGREEN CIR
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-6501
Practice Address - Country:US
Practice Address - Phone:612-840-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA926225200000X
MNA926225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant