Provider Demographics
NPI:1669095477
Name:PATHROSE, JESSICA (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PATHROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 FARGO AVE LOWR FRONT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1768
Mailing Address - Country:US
Mailing Address - Phone:214-957-3060
Mailing Address - Fax:
Practice Address - Street 1:1800 MAPLE RD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2749
Practice Address - Country:US
Practice Address - Phone:716-636-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323640208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics