Provider Demographics
NPI:1508974700
Name:BRUCE, MARY E (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BRUCE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PERKINS SQ
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44308-1063
Mailing Address - Country:US
Mailing Address - Phone:330-543-8224
Mailing Address - Fax:330-543-3648
Practice Address - Street 1:1 PERKINS SQ
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1063
Practice Address - Country:US
Practice Address - Phone:330-543-8224
Practice Address - Fax:330-543-3648
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA2344363AS0400X
NY009354-1363AS0400X
OH50.006760RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199763795Medicaid
MS07950511Medicaid
TNQ002143Medicaid
MS07950511Medicaid