Provider Demographics
NPI:1790768307
Name:WILLIAMS, MARY S (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S. SERVICE RD.
Mailing Address - Street 2:STE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2358
Mailing Address - Country:US
Mailing Address - Phone:516-945-3347
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:100 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346-2130
Practice Address - Country:US
Practice Address - Phone:814-676-7843
Practice Address - Fax:814-676-7838
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN162685L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015509530025OtherMEDICAID GROUP
PA0011861030003Medicaid
PA0015509530025OtherMEDICAID GROUP
PA014731LCUMedicare PIN
PA1014731LCUMedicare PIN