Healthcare Provider Details

I. General information

NPI: 1114902236
Provider Name (Legal Business Name): MARY JANET COY PA-C, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY JANET TYE

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 411 UNIT 28037
APO AE
09112
US

IV. Provider business mailing address

BSC 411 UNIT 28037
APO AE
09112
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA030929
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: