Provider Demographics
NPI:1790793321
Name:PHELAN, MARY T (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:PHELAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5782
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:85 HIGH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203
Practice Address - Country:US
Practice Address - Phone:716-630-1000
Practice Address - Fax:716-859-4035
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF332356-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00027329201OtherUNIVERA
NY161000580OtherNOVA
NY9512998OtherIHA
NY000560974001OtherHEALTH NOW
NY02699521Medicaid
NYQ55400Medicare UPIN