Provider Demographics
NPI:1629621867
Name:DALLAS, MAUREEN T (PNP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:T
Last Name:DALLAS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2890 NIAGARA FALLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-1114
Mailing Address - Country:US
Mailing Address - Phone:716-807-7337
Mailing Address - Fax:716-213-4400
Practice Address - Street 1:2890 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-1114
Practice Address - Country:US
Practice Address - Phone:716-807-7337
Practice Address - Fax:716-213-4400
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383033363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics