Provider Demographics
NPI:1093306227
Name:DICK, MAUREEN E
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:E
Last Name:DICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:325 ESSJAY ROAD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-630-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026258-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant