Provider Demographics
NPI:1346260486
Name:BURES, MARY E (CFNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BURES
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:601-984-5638
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE/DIVISION OF CARDIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR672637363L00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114578Medicaid
MSP00462300OtherRAILROAD MEDICARE PTAN
AL106067Medicaid
MSRR 00229425OtherRAILROAD
MSP00462300OtherRAILROAD MEDICARE PTAN
MSP01077294Medicare PIN
MS302I505854Medicare PIN
MS512I500048Medicare PIN
MS00114578Medicaid