Healthcare Provider Details

I. General information

NPI: 1013471390
Provider Name (Legal Business Name): MARYGRACE HEGARTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRUCE STREET PINE 1 WEST
PHILADELPHIA PA
19107-6130
US

IV. Provider business mailing address

800 SPRUCE STREET PINE 1 WEST
PHILADELPHIA PA
19107-6130
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-7817
  • Fax: 215-829-7129
Mailing address:
  • Phone: 215-829-7817
  • Fax: 215-829-7129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA060374
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: