Healthcare Provider Details

I. General information

NPI: 1184654535
Provider Name (Legal Business Name): MARY PATRICIA OSBORNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 HERRICK ST
BEVERLY MA
01915-5900
US

IV. Provider business mailing address

100 CUMMINGS CTR STE 126Q
BEVERLY MA
01915-6117
US

V. Phone/Fax

Practice location:
  • Phone: 978-927-4110
  • Fax:
Mailing address:
  • Phone: 978-927-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1969
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: