Provider Demographics
NPI:1073769444
Name:SHITTEH, JEROME (NP)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:SHITTEH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CRANBURNE LANE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4971
Mailing Address - Country:US
Mailing Address - Phone:716-308-3576
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-308-3576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-17
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430655-1363LA2100X
NY514256367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care