Basic Information
| Provider Information | |||||||||
| NPI: | 1154730166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUTCHOVER | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822711 | ||||||||
| FaxNumber: | 4692822609 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 JAMES BOWIE DR | ||||||||
| Address2: | |||||||||
| City: | NEW BOSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755702335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145950 | ||||||||
| FaxNumber: | 9036145950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2014 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP125894 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200616050A | 05 | OK | MEDICAID | 350226201 | 05 | TX | MEDICAID |