Provider Demographics
NPI:1942228572
Name:BERTRAM, MARY CAROL (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CAROL
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2131 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7407
Mailing Address - Country:US
Mailing Address - Phone:910-772-9202
Mailing Address - Fax:910-772-9452
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-772-9202
Practice Address - Fax:910-772-9452
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC89423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered