Provider Demographics
NPI:1295760619
Name:LEAIRD KELLY, BRENDA (PA)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:LEAIRD KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:LEAIRD BRIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
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:716-656-4816
Practice Address - Fax:716-817-1766
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
005508363AS0400X
NY005508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00338492OtherMEDICARE RAILROAD
NY000570209005OtherBCBS OF WNY
NY040909000003OtherFIDELIS CARE
NY180049FLOtherPREFERRED CARE
NY11563513OtherCAQH
NY9513175OtherIHA
NY000570209005OtherBCBS OF WNY
NY9513175OtherIHA