Basic Information
| Provider Information | |||||||||
| NPI: | 1942577184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOCKER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14703 AVERY RD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208533605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017625613 | ||||||||
| FaxNumber: | 3017623451 | ||||||||
| Practice Location | |||||||||
| Address1: | 14703 AVERY RD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208533605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017625613 | ||||||||
| FaxNumber: | 3017623451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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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 | 363A00000X | C0000903 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.