Basic Information
| Provider Information | |||||||||
| NPI: | 1104570738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADAM | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284977576 | ||||||||
| FaxNumber: | 2284978869 | ||||||||
| Practice Location | |||||||||
| Address1: | 3603 BIENVILLE BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288189620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2022 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA00637 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA00637 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 00088561 | 05 | MS | MEDICAID |