Provider Demographics
NPI:1215019930
Name:COZZO, DIANE M
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:COZZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:85 HIGH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1149
Practice Address - Country:US
Practice Address - Phone:716-857-8623
Practice Address - Fax:716-250-5907
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303508-1363LA2200X
NY303508363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02429216Medicaid
NYJ400057105Medicare PIN
NYP80700Medicare UPIN