Provider Demographics
NPI:1760899769
Name:MANCUSO, LAUREN MARIA (PA)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:MARIA
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MARIA
Other - Last Name:MICKIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3041 ORCHARD PARK RD STE C
Mailing Address - Street 2:ATT: CREDENTIALING
Mailing Address - City:ORCHARD PAR
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1238
Mailing Address - Country:US
Mailing Address - Phone:716-674-3104
Mailing Address - Fax:716-674-0666
Practice Address - Street 1:6420 TRANSIT RD STE A
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-1033
Practice Address - Country:US
Practice Address - Phone:716-845-1600
Practice Address - Fax:716-242-0201
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04020848Medicaid