Provider Demographics
NPI:1457005001
Name:MASTRANGELO, MARIE (ANP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MASTRANGELO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 SOUTHWESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1732
Mailing Address - Country:US
Mailing Address - Phone:716-972-0279
Mailing Address - Fax:
Practice Address - Street 1:3675 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1732
Practice Address - Country:US
Practice Address - Phone:716-972-0279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310686363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY310686OtherNYS LICENSE