Provider Demographics
NPI:1376320390
Name:MOEBS, MALLORY A (NP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:MOEBS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8276 MILL RD
Mailing Address - Street 2:
Mailing Address - City:GASPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14067-9274
Mailing Address - Country:US
Mailing Address - Phone:716-417-6564
Mailing Address - Fax:
Practice Address - Street 1:3401 ORCHARD PARK RD STE C
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14067-9274
Practice Address - Country:US
Practice Address - Phone:716-674-3104
Practice Address - Fax:716-674-0666
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily