Provider Demographics
NPI:1710116488
Name:CONSTANTINO, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CONSTANTINO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:454 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5532
Mailing Address - Country:US
Mailing Address - Phone:518-587-1141
Mailing Address - Fax:518-587-1152
Practice Address - Street 1:99 E STATE ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1203
Practice Address - Country:US
Practice Address - Phone:518-773-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335787363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid
NYPENDINGMedicare PIN