Provider Demographics
NPI:1174661128
Name:MCCLEARY, MARY JOAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOAN
Last Name:MCCLEARY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JOAN
Other - Last Name:KMECAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:443 HAUPT RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-7234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3494
Practice Address - Country:US
Practice Address - Phone:706-650-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV53126367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00653714OtherRR MEDICARE
WV9333201OtherMEDICARE GROUP
WV0207026000OtherGROUP MEDICAID
WV3810008156Medicaid
WV8238982Medicare PIN