Provider Demographics
NPI:1649622432
Name:EUSTACE, MARY (AGPCNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EUSTACE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:120 E 2ND ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1537
Mailing Address - Country:US
Mailing Address - Phone:814-456-8980
Mailing Address - Fax:814-451-0443
Practice Address - Street 1:3 SILENT MEADOW LN
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-3430
Practice Address - Country:US
Practice Address - Phone:716-934-4518
Practice Address - Fax:716-934-7443
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF307759-1363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health