Provider Demographics
NPI:1548247208
Name:MCCLAIN, MARY GARRETSON (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GARRETSON
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 CAMPUS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-9700
Mailing Address - Country:US
Mailing Address - Phone:276-739-8010
Mailing Address - Fax:276-628-1410
Practice Address - Street 1:24530 FALCON PLACE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7665
Practice Address - Country:US
Practice Address - Phone:276-619-0075
Practice Address - Fax:276-619-0077
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166788363LF0000X
TNAPN0000007851363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01227705OtherRR MEDICARE
TNQ012374Medicaid
VA1548247208Medicaid
VAS93896Medicare UPIN
VAQ38505AMedicare PIN
TN10350I1000Medicare PIN