Basic Information
| Provider Information | |||||||||
| NPI: | 1629006010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | MARY ANN | ||||||||
| MiddleName: | SNYDER | ||||||||
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| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | MARY ANN | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1803 MOUNT ROSE AVE | ||||||||
| Address2: | SUITE B3 | ||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516162 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PINE GROVE COMMONS | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178515736 | ||||||||
| FaxNumber: | 7178516162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP008753 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RH0002X | SP008753 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102499 | 01 | PA | JOHNS HOPKINS | OTHER | 1551918 | 01 | PA | GATEWAY-WMG | OTHER | 50054751 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | 648377 | 01 | MD | CAREFIRST MD BCBS | OTHER |