Healthcare Provider Details

I. General information

NPI: 1902807019
Provider Name (Legal Business Name): MARY S MCLAUGHLIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 TAYLORSVILLE RD
TAYLORSVILLE KY
40071-7798
US

IV. Provider business mailing address

404 NICKLEBY WAY
LOUISVILLE KY
40245-4066
US

V. Phone/Fax

Practice location:
  • Phone: 502-477-8838
  • Fax: 502-477-2273
Mailing address:
  • Phone: 502-396-1952
  • Fax: 502-477-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA135
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: