Provider Demographics
NPI:1417244773
Name:MCKENNA, PETER FRANCIS (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:FRANCIS
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 SPINDRIFT DR
Mailing Address - Street 2:STE 100
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7894
Mailing Address - Country:US
Mailing Address - Phone:716-986-9199
Mailing Address - Fax:
Practice Address - Street 1:34 BENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-1761
Practice Address - Country:US
Practice Address - Phone:716-986-9199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014820-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03370638Medicaid
J400056340Medicare PIN