Provider Demographics
NPI:1982765392
Name:DAGUSTO, MARY ELLEN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:
Last Name:DAGUSTO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W SANDY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-2106
Mailing Address - Country:US
Mailing Address - Phone:215-534-3498
Mailing Address - Fax:
Practice Address - Street 1:595 W STATE ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2554
Practice Address - Country:US
Practice Address - Phone:215-345-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007042C363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA055331ETLMedicare ID - Type Unspecified
PAP51793Medicare UPIN