Provider Demographics
NPI:1578593315
Name:STANSBERRY, ANDREW J (PA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:STANSBERRY
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 1:52 BROOKEDGE RD
Mailing Address - Street 2:RD
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4203
Mailing Address - Country:US
Mailing Address - Phone:716-668-4906
Mailing Address - Fax:
Practice Address - Street 1:565 ABBOTT RD
Practice Address - Street 2:@ MERCY HOSPTIAL OF BUFFALO
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-2039
Practice Address - Country:US
Practice Address - Phone:518-383-5450
Practice Address - Fax:518-383-4223
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY006296-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02341404Medicaid
NYDD5472Medicare ID - Type UnspecifiedINDV.MEDICARE # FOR GROUP
NYS28629Medicare UPIN