Basic Information
| Provider Information | |||||||||
| NPI: | 1174687271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOLLE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 DARRINGTON DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275138158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198523999 | ||||||||
| FaxNumber: | 9193789114 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 JONES FERRY RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275106113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199291747 | ||||||||
| FaxNumber: | 9199335168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 103323 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | 103323 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8101937 | 05 | NC | MEDICAID | P00938348 | 01 | NC | RR MEDICARE | OTHER |