Healthcare Provider Details

I. General information

NPI: 1124416508
Provider Name (Legal Business Name): MARY BURNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 SW BARNES RD STE 875
PORTLAND OR
97225-6683
US

IV. Provider business mailing address

8614 E MILL PLAIN BLVD STE 400
VANCOUVER WA
98664-2092
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-3440
  • Fax:
Mailing address:
  • Phone: 541-728-1019
  • Fax: 360-254-6089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA170904
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: