Provider Demographics
NPI:1326002916
Name:EWING, MARY C (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:EWING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8114
Mailing Address - Country:US
Mailing Address - Phone:605-355-2443
Mailing Address - Fax:605-355-2403
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2443
Practice Address - Fax:605-355-2403
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000258363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549050Medicaid
SD8HAZ12Medicare ID - Type Unspecified
SDP73833Medicare UPIN