Provider Demographics
NPI:1396479440
Name:NUSSBAUM, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 MUNSON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3580
Mailing Address - Country:US
Mailing Address - Phone:319-358-7172
Mailing Address - Fax:231-935-9230
Practice Address - Street 1:550 MUNSON AVE STE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-935-8717
Practice Address - Fax:231-935-9230
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENAMedicaid