Provider Demographics
NPI:1083616452
Name:MRAZ, MARY (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MRAZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAINE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2026
Mailing Address - Country:US
Mailing Address - Phone:207-725-5197
Mailing Address - Fax:207-798-4658
Practice Address - Street 1:14 MAINE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2026
Practice Address - Country:US
Practice Address - Phone:207-725-5197
Practice Address - Fax:207-798-4658
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017035363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
B86291Medicare UPIN
MM0278Medicare ID - Type Unspecified