Provider Demographics
NPI:1679511281
Name:ROSENHAUER, MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROSENHAUER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5336
Mailing Address - Country:US
Mailing Address - Phone:618-529-2955
Mailing Address - Fax:
Practice Address - Street 1:1350 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5336
Practice Address - Country:US
Practice Address - Phone:618-529-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001667363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-001667OtherSTATE LICENSE NUMBER
IL085-001667OtherSTATE LICENSE NUMBER
ILK16193Medicare UPIN
ILK16192Medicare UPIN
ILP90328Medicare UPIN
IL209286Medicare PIN
IL205945Medicare PIN