Provider Demographics
NPI:1992883177
Name:PLUNKETT, MARY W (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:PLUNKETT
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 1:4260 FRONTIER RD
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-3009
Mailing Address - Country:US
Mailing Address - Phone:215-674-2976
Mailing Address - Fax:
Practice Address - Street 1:7600 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2442
Practice Address - Country:US
Practice Address - Phone:215-728-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002583L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP61012Medicare UPIN
PA070988Medicare ID - Type Unspecified