Provider Demographics
NPI:1659306470
Name:WARD, MARY TRAVER (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:TRAVER
Last Name:WARD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:TRAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 Q ST FL 2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-7058
Practice Address - Country:US
Practice Address - Phone:916-733-3460
Practice Address - Fax:916-733-3472
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR106262363L00000X
CA23079363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147204600Medicaid
MDP34874Medicare UPIN
MD144ME635Medicare ID - Type Unspecified