Provider Demographics
NPI: | 1013933597 |
---|---|
Name: | WHITESIDE, BARBARA Y (PA) |
Entity Type: | Individual |
Prefix: | |
First Name: | BARBARA |
Middle Name: | Y |
Last Name: | WHITESIDE |
Suffix: | |
Gender: | F |
Credentials: | PA |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
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: | 14221-8235 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 716-630-1219 |
Mailing Address - Fax: | 716-817-1726 |
Practice Address - Street 1: | 3900 N BUFFALO ST |
Practice Address - Street 2: | |
Practice Address - City: | ORCHARD PARK |
Practice Address - State: | NY |
Practice Address - Zip Code: | 14127-1842 |
Practice Address - Country: | US |
Practice Address - Phone: | 716-630-1000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-15 |
Last Update Date: | 2021-12-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 011281 | 363AS0400X |
363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 02823518 | Medicaid | |
NY | 02823518 | Medicaid |