Provider Demographics
NPI:1144201476
Name:MCCLURG, PENELOPE LYN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:PENELOPE
Middle Name:LYN
Last Name:MCCLURG
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:LYN
Other - Last Name:OSTOLSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4225 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1994
Mailing Address - Country:US
Mailing Address - Phone:716-204-3200
Mailing Address - Fax:
Practice Address - Street 1:111 N MAPLEMERE RD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3182
Practice Address - Country:US
Practice Address - Phone:716-204-3200
Practice Address - Fax:716-204-4337
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005649-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005649OtherLICENSE