Provider Demographics
NPI:1477031342
Name:SMITH, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:SHABEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6569
Mailing Address - Fax:
Practice Address - Street 1:7 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:NY
Practice Address - Zip Code:13135-1906
Practice Address - Country:US
Practice Address - Phone:315-695-4700
Practice Address - Fax:315-695-4706
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343417363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily