Healthcare Provider Details

I. General information

NPI: 1457389496
Provider Name (Legal Business Name): MARY G BROWN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY G BRENYO BROWN PA

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE STE B101
LEXINGTON KY
40536-6514
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD SUITE 100
KNOXVILLE TN
37932-1984
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5661
  • Fax: 859-323-6411
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA642
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA642
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA642
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: