Provider Demographics
NPI:1043305246
Name:FELLENZ, MONICA E (PA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:E
Last Name:FELLENZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 THOMAS INDIAN SCHOOL DR
Mailing Address - Street 2:CATTARAUGUS INDIAN RESERVATION HEALTH CENTER
Mailing Address - City:IRVING
Mailing Address - State:NY
Mailing Address - Zip Code:14081-9300
Mailing Address - Country:US
Mailing Address - Phone:716-532-5582
Mailing Address - Fax:716-532-2597
Practice Address - Street 1:36 THOMAS INDIAN SCHOOL DR
Practice Address - Street 2:CATTARAUGUS INDIAN RESERVATION HEALTH CENTER
Practice Address - City:IRVING
Practice Address - State:NY
Practice Address - Zip Code:14081-9300
Practice Address - Country:US
Practice Address - Phone:716-532-5582
Practice Address - Fax:716-532-2597
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY008548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000528450001OtherWNYBCBS
NY9513195OtherINDEPENDENT HEALTH
NY060822000001OtherFIDELIS CARE NEW YORK
NY9513195OtherINDEPENDENT HEALTH
NCP84431Medicare UPIN
NYPA1325Medicare PIN