Provider Demographics
NPI:1164447686
Name:DEROSA, MARY B (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:DEROSA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 550, 2 CATHARINE STREET
Mailing Address - Street 2:MID-HUDSON ANETHESIOLOGIST, PC
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12602
Mailing Address - Country:US
Mailing Address - Phone:866-885-2318
Mailing Address - Fax:845-790-2675
Practice Address - Street 1:70 DUBOI STREET
Practice Address - Street 2:ST. LUKES HOSPITAL
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550
Practice Address - Country:US
Practice Address - Phone:845-561-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400637367500000X
NY400637-1367500000X
PARN357926L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered