Provider Demographics
NPI:1003841156
Name:NOLAN, MARY L (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:NOLAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:ZUERCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1150 YOUNGS RD
Mailing Address - Street 2:STE 104
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8024
Mailing Address - Country:US
Mailing Address - Phone:716-636-7990
Mailing Address - Fax:716-929-0192
Practice Address - Street 1:565 ABBOTT RD
Practice Address - Street 2:@ MERCY HOSPITAL OF BUFFALO
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-2039
Practice Address - Country:US
Practice Address - Phone:518-383-5450
Practice Address - Fax:518-383-4223
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005299-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01627307Medicaid
NYPA0165Medicare ID - Type UnspecifiedINDV.MEDICARE # FOR GROUP
NY01627307Medicaid