Provider Demographics
NPI:1073094769
Name:VANDERWALL, KRISTA LAUREN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LAUREN
Last Name:VANDERWALL
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:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-0488
Mailing Address - Country:US
Mailing Address - Phone:716-852-4772
Mailing Address - Fax:
Practice Address - Street 1:100 COLLEGE PKWY STE 160
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6800
Practice Address - Country:US
Practice Address - Phone:716-500-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY022744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program