Provider Demographics
NPI:1346590296
Name:MAMON, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:MAMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2069 TWO ROD RD
Mailing Address - Street 2:
Mailing Address - City:MARILLA
Mailing Address - State:NY
Mailing Address - Zip Code:14102-9734
Mailing Address - Country:US
Mailing Address - Phone:716-863-2153
Mailing Address - Fax:
Practice Address - Street 1:818 ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1021
Practice Address - Country:US
Practice Address - Phone:716-323-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY660142-1163W00000X
NYF343353-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse