Provider Demographics
NPI:1437599297
Name:HERMISTON, MARA GROOM (DO)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:GROOM
Last Name:HERMISTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 HIGHWAY 71 STE C
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1253
Mailing Address - Country:US
Mailing Address - Phone:712-336-3750
Mailing Address - Fax:
Practice Address - Street 1:2301 HIGHWAY 71 STE C
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1253
Practice Address - Country:US
Practice Address - Phone:712-336-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-9859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine