Healthcare Provider Details

I. General information

NPI: 1790563211
Provider Name (Legal Business Name): MARY ALEXIS TULLY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ALEXIS HALL

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-7000
  • Fax:
Mailing address:
  • Phone: 910-667-2606
  • Fax: 910-815-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13667
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: