Basic Information
| Provider Information | |||||||||
| NPI: | 1700825502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514705842 | ||||||||
| FaxNumber: | 2514705809 | ||||||||
| Practice Location | |||||||||
| Address1: | 1504 SPRINGHILL AVE | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366043207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514343475 | ||||||||
| FaxNumber: | 2514343837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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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 | 363L00000X | 1-067016 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 05420342 | 05 | MS | MEDICAID | 51532878 | 01 | AL | BLUE CROSS | OTHER |