Healthcare Provider Details

I. General information

NPI: 1043296817
Provider Name (Legal Business Name): MARY M CUMMINS P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4938 BROWNSBORO RD STE 206
LOUISVILLE KY
40222-6385
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 502-339-2922
  • Fax: 502-339-2912
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3213
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: