Provider Demographics
NPI:1508081613
Name:EDER, MARY (RPA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EDER
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6805 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9748
Mailing Address - Country:US
Mailing Address - Phone:716-947-5568
Mailing Address - Fax:
Practice Address - Street 1:1900 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3332
Practice Address - Country:US
Practice Address - Phone:716-712-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009301363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical