=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396816732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY-JANE CROSS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 STEVENS ST
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-853-3464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 148 GREENS FARMS RD
-----------------------------------------------------
City | WESTPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06880-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-454-5938
-----------------------------------------------------
Fax | 203-454-7142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 000764
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------