Healthcare Provider Details

I. General information

NPI: 1275635369
Provider Name (Legal Business Name): MARY E SHOWSTARK PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELIZABETH SHOWSTARK

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 W 23RD ST # 33 PHYSICIAN ASSISTANT PROGRAM
NEW YORK NY
10010-4202
US

IV. Provider business mailing address

27 W 23RD ST PHYSICIAN ASSISTANT PROGRAM
NEW YORK NY
10010-4202
US

V. Phone/Fax

Practice location:
  • Phone: 212-463-0400
  • Fax:
Mailing address:
  • Phone: 212-463-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18197
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberAMD-284
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: