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NPI Code Detail

MEDICARE: MARY LYNNE FELLER

MEDICARE: MARY LYNNE FELLER
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
1363A00000XPhysician Assistant002974-1NY

General Provider Information

NPI Number : 1376751339
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY LYNNE FELLER
Provider Business Mailing Address
First Line : 10 LINCOLN DR
Second Line : PO BOX 1243
City : TUPPER LAKE
State : NY
Zip : 12986-1517
Country : US
Telephone Number : 518-359-3311
Fax Number :
Provider Business Practice Location Address
First Line : 2445 STATE ROUTE 30
Second Line :
City : TUPPER LAKE
State : NY
Zip : 12986-2502
Country : US
Telephone Number : 518-359-3311
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/21/2007
Last Update Date : 07/08/2007

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Directions to “ MARY LYNNE FELLER ” Practice Location

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