Provider Demographics
NPI:1790712743
Name:MESROBIAN, MARY SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY SUSAN
Middle Name:
Last Name:MESROBIAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY SUSAN
Other - Middle Name:
Other - Last Name:SEIFERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0705
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-3138
Practice Address - Fax:540-982-2719
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001101441367500000X
VA0024101441367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC896433F54Medicare PIN