Provider Demographics
NPI:1578602017
Name:DOUGHERTY, MARY JO (PA - C)
Entity type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:DOUGHERTY
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 1:700 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3728
Mailing Address - Country:US
Mailing Address - Phone:757-977-8500
Mailing Address - Fax:757-904-1703
Practice Address - Street 1:700 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3728
Practice Address - Country:US
Practice Address - Phone:757-977-8500
Practice Address - Fax:757-904-1703
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000574363AM0700X
VA0110003585363AM0700X
PAMA052848363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical