Provider Demographics
NPI:1841419017
Name:DOUR, MARY A (RN, APN,C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:DOUR
Suffix:
Gender:F
Credentials:RN, APN,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-5931
Mailing Address - Country:US
Mailing Address - Phone:201-317-2925
Mailing Address - Fax:
Practice Address - Street 1:1440 WOOD ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-5931
Practice Address - Country:US
Practice Address - Phone:201-317-2925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN05287600363LF0000X
PASP008143363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ191220ZB66Medicare PIN
NJS71558Medicare UPIN
NJ023341Medicare ID - Type UnspecifiedHCFA PIN