Provider Demographics
NPI:1619091436
Name:ENSMAN, MARY BARBARA (PA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BARBARA
Last Name:ENSMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:42 TWIN ORCHARD DRIVE
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-1312
Mailing Address - Country:US
Mailing Address - Phone:315-343-5064
Mailing Address - Fax:315-343-5064
Practice Address - Street 1:110 WEST 6TH STREET
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1312
Practice Address - Country:US
Practice Address - Phone:315-349-5598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004416-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical