Provider Demographics
NPI:1588838635
Name:BARDIS, MARY A (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:BARDIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2925
Mailing Address - Country:US
Mailing Address - Phone:518-229-8559
Mailing Address - Fax:
Practice Address - Street 1:74 MARGARET ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2925
Practice Address - Country:US
Practice Address - Phone:518-229-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-19
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005021-2171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist