Provider Demographics
NPI:1265169627
Name:VAN FOSSEN, MARA MARIE (NP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:MARIE
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:380 SUMMIT AVENUE
Mailing Address - Street 2:MSO PHYSICIAN BILLING
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-283-7597
Mailing Address - Fax:740-283-7807
Practice Address - Street 1:107 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-3733
Practice Address - Country:US
Practice Address - Phone:740-264-1656
Practice Address - Fax:740-266-2936
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0031865363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000385Medicaid