Provider Demographics
NPI:1144776345
Name:WOOD-FOSSEN, MARY (BS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WOOD-FOSSEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 WILLIAMS
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785
Mailing Address - Country:US
Mailing Address - Phone:605-347-3003
Mailing Address - Fax:605-347-4944
Practice Address - Street 1:1807 WILLIAMS
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785
Practice Address - Country:US
Practice Address - Phone:605-347-3003
Practice Address - Fax:605-347-4944
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD05051230174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1013057330Medicaid