Provider Demographics
NPI:1992738710
Name:NOBLE, MARY (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NOBLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7870W US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-8992
Mailing Address - Country:US
Mailing Address - Phone:906-341-2153
Mailing Address - Fax:906-341-3299
Practice Address - Street 1:500 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1522
Practice Address - Country:US
Practice Address - Phone:906-341-2153
Practice Address - Fax:906-341-3299
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G71004OtherRHC BC NUMBER
MI0G71004OtherRHC BC NUMBER
MI23-8588Medicare ID - Type UnspecifiedRHC MEDICARE NUMBER