Provider Demographics
NPI:1780978072
Name:D'AGOSTINO, MARY GENEVIEVE (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GENEVIEVE
Last Name:D'AGOSTINO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 IRVINGTON PL
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-5216
Mailing Address - Country:US
Mailing Address - Phone:484-678-8690
Mailing Address - Fax:
Practice Address - Street 1:2655 NORTHWINDS PARKWAY
Practice Address - Street 2:PREMIER ANESTHESIA
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009
Practice Address - Country:US
Practice Address - Phone:877-742-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN559969367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered