Provider Demographics
NPI:1275598930
Name:BROOKS, MARY (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:BROOKS
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 1:215 ELMWOOD AVENUE
Mailing Address - Street 2:PO BOX 2169
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903
Mailing Address - Country:US
Mailing Address - Phone:607-733-3639
Mailing Address - Fax:607-733-1292
Practice Address - Street 1:207 FOOTE AVENUE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14702
Practice Address - Country:US
Practice Address - Phone:716-487-0141
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284806367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS50387Medicare UPIN
NYCC7717Medicare ID - Type Unspecified