Basic Information
Provider Information | |||||||||
NPI: | 1790767705 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOLBERT | ||||||||
FirstName: | MARY SUSAN | ||||||||
MiddleName: | SHAW | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHAW | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | SUSAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1511 DONELSON PKWY | ||||||||
Address2: | WOMACK ARMY MEDICAL CENTER | ||||||||
City: | DOVER | ||||||||
State: | TN | ||||||||
PostalCode: | 370583749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109078922 | ||||||||
FaxNumber: | 9109076069 | ||||||||
Practice Location | |||||||||
Address1: | BUILDING C-1722 | ||||||||
Address2: | TAGATAY AND GRUBER RD. | ||||||||
City: | FORT BRAGG | ||||||||
State: | NC | ||||||||
PostalCode: | 283100001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109078282 | ||||||||
FaxNumber: | 9109079360 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 01/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0000001709 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 7044670 | 05 | WA |   | MEDICAID |