MEDICARE: MS. MARY ELIZABETH DOLAN P.A.

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	363AM0700X	Medical Physician Assistant	2005040394	MO
2	363A00000X	Physician Assistant	2005040394	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2005040394	OTHER	MO	P.A. LICENSE

General Provider Information

NPI Number	:	1821013137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ELIZABETH DOLAN P.A.

Provider Business Mailing Address
First Line	:	6763 PAGE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1635
Country	:	US
Telephone Number	:	314-678-9857
Fax Number	:

Provider Business Practice Location Address
First Line	:	6763 PAGE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1635
Country	:	US
Telephone Number	:	314-678-9857
Fax Number	:

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/21/2022

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