Provider Demographics
NPI:1962469817
Name:REISS, MARY J (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:REISS
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:5300 ALPINE DR NW
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-4778
Practice Address - Country:US
Practice Address - Phone:612-427-7180
Practice Address - Fax:612-427-6936
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN9208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
R81628Medicare UPIN