Provider Demographics
NPI:1114382520
Name:PURE PODIATRY OF WNY PLLC
Entity Type:Organization
Organization Name:PURE PODIATRY OF WNY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BREEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:716-897-3720
Mailing Address - Street 1:1094 E LOVEJOY ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14206-1127
Mailing Address - Country:US
Mailing Address - Phone:716-897-3720
Mailing Address - Fax:716-897-3918
Practice Address - Street 1:1094 E LOVEJOY ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14206-1127
Practice Address - Country:US
Practice Address - Phone:716-897-3720
Practice Address - Fax:716-897-3918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006328213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty