Provider Demographics
NPI:1164489415
Name:DIEBOLD, ERIN E (PA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:E
Last Name:DIEBOLD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 GARDENVILLE PKWY W
Mailing Address - Street 2:ATTN: BETTY PICCILLO
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1324
Mailing Address - Country:US
Mailing Address - Phone:716-857-6150
Mailing Address - Fax:716-656-4074
Practice Address - Street 1:120 GARDENVILLE PARKWAY WEST
Practice Address - Street 2:WEST SENECA HEALTH CENTER
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224
Practice Address - Country:US
Practice Address - Phone:716-668-3600
Practice Address - Fax:716-656-4223
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9513164OtherIHA
NY11563367OtherCAQH
NY040511000518OtherFIDELIS CARE
NY000570455002OtherBCBS OF WNY
NY177012DLOtherPREFERRED CARE