Basic Information
| Provider Information | |||||||||
| NPI: | 1952589392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BYRNE | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5515 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165092695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148688294 | ||||||||
| FaxNumber: | 8148682489 | ||||||||
| Practice Location | |||||||||
| Address1: | 5515 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165092695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148688294 | ||||||||
| FaxNumber: | 8148682489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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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 | 363A00000X | 0110002704 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | OT019106 | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1952589392 | 05 | VA | MEDICAID | 10113082P | 01 | VA | SENTARA HEALTH PLANS | OTHER | 1952589392 | 01 | VA | TRICARE | OTHER |