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NPI Code Detail

MEDICARE: MR. JERRY L CORP II PMHNP-BC

MEDICARE: MR. JERRY L CORP II PMHNP-BC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse Practitioner402647NY

General Provider Information

NPI Number : 1003261322
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JERRY L CORP II PMHNP-BC
Provider Business Mailing Address
First Line : 255 DELAWARE AVE
Second Line :
City : BUFFALO
State : NY
Zip : 14202-2016
Country : US
Telephone Number : 716-884-0888
Fax Number :
Provider Business Practice Location Address
First Line : 255 DELAWARE AVE
Second Line :
City : BUFFALO
State : NY
Zip : 14202-2016
Country : US
Telephone Number : 716-884-0888
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/25/2016
Last Update Date : 02/07/2020

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