Basic Information
| Provider Information | |||||||||
| NPI: | 1467560516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERNON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 46 | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674020046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163004021 | ||||||||
| FaxNumber: | 3163004040 | ||||||||
| Practice Location | |||||||||
| Address1: | 4951 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660472090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858416540 | ||||||||
| FaxNumber: | 7858413129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0417719 | KS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 417719 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100193860C | 05 | KS | MEDICAID |