Basic Information
| Provider Information | |||||||||
| NPI: | 1710116488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONSTANTINO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
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| OtherLastName: | GREEN | ||||||||
| OtherFirstName: | MARY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 454 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128665532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185871141 | ||||||||
| FaxNumber: | 5185871152 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187735780 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
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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 | F335787 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NY | MEDICAID |