MEDICARE: MARY C MCNICHOLAS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA14376	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295791960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY C MCNICHOLAS PA

Provider Business Mailing Address
First Line	:	2100 POWELL ST
Second Line	:	SUITE 920
City	:	EMERYVILLE
State	:	CA
Zip	:	94608-1826
Country	:	US
Telephone Number	:	510-350-2655
Fax Number	:	510-879-9071

Provider Business Practice Location Address
First Line	:	2100 POWELL ST
Second Line	:	SUITE 920
City	:	EMERYVILLE
State	:	CA
Zip	:	94608-1826
Country	:	US
Telephone Number	:	510-350-2655
Fax Number	:	510-879-9071

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	12/16/2008

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