Healthcare Provider Details

I. General information

NPI: 1326002916
Provider Name (Legal Business Name): MARY C EWING FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

IV. Provider business mailing address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

V. Phone/Fax

Practice location:
  • Phone: 605-355-2443
  • Fax: 605-355-2403
Mailing address:
  • Phone: 605-355-2443
  • Fax: 605-355-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000258
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: