Provider Demographics
NPI:1134115645
Name:MAZZA, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MAZZA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 W TAFT RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-2800
Mailing Address - Country:US
Mailing Address - Phone:315-448-6215
Mailing Address - Fax:
Practice Address - Street 1:4820 W TAFT RD
Practice Address - Street 2:SUITE 209
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-2800
Practice Address - Country:US
Practice Address - Phone:315-448-6215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331446363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S08938Medicare UPIN