Healthcare Provider Details

I. General information

NPI: 1477610756
Provider Name (Legal Business Name): PAMELA A WALCK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER ST
BUFFALO NY
14215-3021
US

IV. Provider business mailing address

3165 UPPER MOUNTAIN RD
SANBORN NY
14132-9103
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-3920
  • Fax: 716-898-3259
Mailing address:
  • Phone: 716-731-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number014336-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: