Provider Demographics
NPI:1780780080
Name:SCHROEDER, MARIANNE T (PA)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:T
Last Name:SCHROEDER
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:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14702-1258
Mailing Address - Country:US
Mailing Address - Phone:716-487-1124
Mailing Address - Fax:716-487-2488
Practice Address - Street 1:WCA HOSPITAL, 207 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701
Practice Address - Country:US
Practice Address - Phone:716-487-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS12530Medicare UPIN