Provider Demographics
NPI:1962843862
Name:PIERSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PIERSON
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 1:6735 54TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:ND
Mailing Address - Zip Code:58529
Mailing Address - Country:US
Mailing Address - Phone:701-622-3088
Mailing Address - Fax:
Practice Address - Street 1:6735 54TH AVE SW
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:ND
Practice Address - Zip Code:58529
Practice Address - Country:US
Practice Address - Phone:701-622-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND56227172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND04966OtherFOSTER PARENT
ND56227OtherMEDICAID TRANSPORTATION PROVIDER