Healthcare Provider Details

I. General information

NPI: 1245894641
Provider Name (Legal Business Name): MARY NONACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 NASHUA RD
BEDFORD NH
03110-5515
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 603-472-6700
  • Fax:
Mailing address:
  • Phone: 603-410-6700
  • Fax: 603-319-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1670
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: