Provider Demographics
NPI:1922161322
Name:BETZ, MARY KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:BETZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:BETZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:LANDMARK HEALTH
Mailing Address - Street 2:701 SENECA ST SUITE 646
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210
Mailing Address - Country:US
Mailing Address - Phone:716-995-4450
Mailing Address - Fax:
Practice Address - Street 1:LANDMARK HEALTH
Practice Address - Street 2:701 SENECA ST SUITE 646
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210
Practice Address - Country:US
Practice Address - Phone:716-995-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026554701OtherUNIVERA
NY000570245003OtherBLUE CROSS & BLUE SHIELD
NY000570245004OtherBLUE CROSS & BLUE SHIELD
NY9512248OtherINDEPENDENT HEALTH
NY9512248OtherINDEPENDENT HEALTH
NYPA0233Medicare ID - Type Unspecified