Provider Demographics
NPI:1801205695
Name:SWEENEY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SWEENEY
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 1:507 AIRPORT EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-5238
Mailing Address - Country:US
Mailing Address - Phone:845-262-5313
Mailing Address - Fax:
Practice Address - Street 1:350 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3049
Practice Address - Country:US
Practice Address - Phone:845-634-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant