Basic Information
| Provider Information | |||||||||
| NPI: | 1912927237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTHERLAND | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JOSEPHINE | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3189 HIGHWAY 17 | ||||||||
| Address2: | |||||||||
| City: | GREEN COVE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320439371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046210247 | ||||||||
| FaxNumber: | 9043399945 | ||||||||
| Practice Location | |||||||||
| Address1: | 3189 US HIGHWAY 17 | ||||||||
| Address2: | |||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320037109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046210247 | ||||||||
| FaxNumber: | 9043399945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2225 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA2225 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 291115900 | 05 | FL | MEDICAID |