MEDICARE: MARY C. VANDERGRIFT PA-C

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	0110002290	VA

General Provider Information

NPI Number	:	1518041722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY C. VANDERGRIFT PA-C

Provider Business Mailing Address
First Line	:	213 S JEFFERSON ST STE 1006
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24011-1713
Country	:	US
Telephone Number	:	540-224-5352
Fax Number	:

Provider Business Practice Location Address
First Line	:	5673 AIRPORT RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24012-1119
Country	:	US
Telephone Number	:	540-523-8080
Fax Number	:	540-562-8867

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	04/20/2023

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