Provider Demographics
NPI:1124383062
Name:CROUSE, MARY KATHERINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:CROUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE DR NW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-2013
Mailing Address - Country:US
Mailing Address - Phone:252-291-1732
Mailing Address - Fax:
Practice Address - Street 1:1001 LAKESIDE DR NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-2013
Practice Address - Country:US
Practice Address - Phone:252-291-1732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC165894163W00000X
NC91082367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse