1063661940 NPI number — MARY JANE SMALLEY CPNP

Table of content: TATYANA SLYUSARANSKAYA PA-C (NPI 1497997290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063661940 NPI number — MARY JANE SMALLEY CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALLEY
Provider First Name:
MARY JANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063661940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 8500
Provider Second Line Business Mailing Address:
SHRINERS HOSPITALS FOR CHILDREN LOCKBOX #7642
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-7642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-281-8478
Provider Business Mailing Address Fax Number:
813-281-8113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1645 WEST 8TH STREET
Provider Second Line Business Practice Location Address:
SHRINERS HOSPITALS FOR CHILDREN ERIE
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16505-5097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-873-5437
Provider Business Practice Location Address Fax Number:
814-875-8796
Provider Enumeration Date:
09/16/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  382009 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: SP009524 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)