Provider Demographics
NPI:1528180080
Name:DECKER, MARY LOU (PA)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1806
Mailing Address - Country:US
Mailing Address - Phone:716-863-0196
Mailing Address - Fax:
Practice Address - Street 1:964 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1806
Practice Address - Country:US
Practice Address - Phone:716-863-0196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0003041-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical