Provider Demographics
NPI:1407323546
Name:WIATROWSKI, LAUREN SAMANTHA
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:SAMANTHA
Last Name:WIATROWSKI
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 1:2475 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2475 HARLEM RD # 4558
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-4558
Practice Address - Country:US
Practice Address - Phone:716-322-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025135363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical