Basic Information
| Provider Information | |||||||||
| NPI: | 1760485932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | MARY JO | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 W WILLIAM CANNON DR | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787455253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124167246 | ||||||||
| FaxNumber: | 5122752833 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 S AUSTIN AVE | ||||||||
| Address2: | SUITE 265 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786267545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124167246 | ||||||||
| FaxNumber: | 5122752833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 06/14/2017 | ||||||||
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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 | 363AM0700X | PA03126 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA03126 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 194811901 | 05 | TX | MEDICAID | 194811902 | 05 | TX | MEDICAID |