Provider Demographics
NPI:1598751455
Name:CONNELLY, LARA A (MS, RPAC)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:A
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MS, RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1156
Mailing Address - Country:US
Mailing Address - Phone:716-523-2090
Mailing Address - Fax:
Practice Address - Street 1:219 BRYANT ST
Practice Address - Street 2:DEPT OF NEONATOLOGY
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-2006
Practice Address - Country:US
Practice Address - Phone:716-878-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010777-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical