Provider Demographics
NPI:1780635706
Name:SNYDER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SNYDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 5TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7360
Mailing Address - Country:US
Mailing Address - Phone:605-343-7208
Mailing Address - Fax:605-343-7132
Practice Address - Street 1:3615 5TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6014
Practice Address - Country:US
Practice Address - Phone:605-343-7208
Practice Address - Fax:605-343-7132
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21329207Y00000X, 2086S0122X
SD59842086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026079700Medicaid
NE47078557586Medicaid
NE47078557586Medicaid
NEI34612Medicare UPIN
NE279130Medicare ID - Type Unspecified