Provider Demographics
NPI:1184654535
Name:OSBORNE, MARY PATRICIA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CTR STE 126Q
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6117
Mailing Address - Country:US
Mailing Address - Phone:978-927-0601
Mailing Address - Fax:
Practice Address - Street 1:75 HERRICK ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-5900
Practice Address - Country:US
Practice Address - Phone:978-927-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1969363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAOS-AP2462Medicare ID - Type Unspecified