Provider Demographics
NPI:1679102347
Name:HERRERA, MARY (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HERRERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6353 CENTER DR STE 204
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-0001
Mailing Address - Country:US
Mailing Address - Phone:757-461-3313
Mailing Address - Fax:
Practice Address - Street 1:6353 CENTER DR STE 204
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-0001
Practice Address - Country:US
Practice Address - Phone:757-461-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-05
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006986363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical