Provider Demographics
NPI:1982833307
Name:O'DONNELL, MARY R (RPA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:RPA-C
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Mailing Address - Street 1:791 N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757
Mailing Address - Country:US
Mailing Address - Phone:631-957-2200
Mailing Address - Fax:631-957-4619
Practice Address - Street 1:80 CROSSWAYS PARK DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2047
Practice Address - Country:US
Practice Address - Phone:631-796-9488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2018-09-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY004014363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPO2792Medicare UPIN