Provider Demographics
NPI:1538452149
Name:NOONAN, MARY C (RPA-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:C
Last Name:NOONAN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2401
Mailing Address - Country:US
Mailing Address - Phone:516-439-6912
Mailing Address - Fax:
Practice Address - Street 1:79 AVENUE C
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-4210
Practice Address - Country:US
Practice Address - Phone:516-439-6912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0070781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant