Provider Demographics
NPI:1114915287
Name:FRIES, LYNNE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:MARIE
Last Name:FRIES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 HARLEM ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3822
Mailing Address - Country:US
Mailing Address - Phone:716-839-6720
Mailing Address - Fax:716-839-6740
Practice Address - Street 1:219 BRYANT STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-2006
Practice Address - Country:US
Practice Address - Phone:716-250-6545
Practice Address - Fax:716-250-6566
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006966-1363AM0700X
NY006966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000560443011OtherBC/BS
00026514404OtherUNIVERA
9512047OtherIHA
NY000560443006OtherBLUE CROSS/COMMUNITY BLUE
070924000060OtherFIDELIS
NY02759662Medicaid
NYR54766Medicare UPIN
070924000060OtherFIDELIS
NY02759662Medicaid