Provider Demographics
NPI:1164997193
Name:GANDT, MICHAEL JEFFREY (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEFFREY
Last Name:GANDT
Suffix:
Gender:M
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 1:861 GEORGE URBAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4203
Mailing Address - Country:US
Mailing Address - Phone:716-341-9367
Mailing Address - Fax:
Practice Address - Street 1:861 GEORGE URBAN BLVD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4203
Practice Address - Country:US
Practice Address - Phone:716-341-9367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant