Provider Demographics
NPI:1275717795
Name:FORBEAR, MARY DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DANIELLE
Last Name:FORBEAR
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 1:1 HAWK DR
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-2447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 HAWK DR
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-2447
Practice Address - Country:US
Practice Address - Phone:855-554-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012249363A00000X
MO2007037236363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY00695941Medicaid
NY331945Medicare PIN
NY331946Medicare PIN
NY331944Medicare PIN
NY331956Medicare PIN
NY331943Medicare PIN
NY331947Medicare PIN
NYW6L111Medicare PIN
NY331978Medicare PIN
NY331952Medicare PIN
NY331957Medicare PIN