Healthcare Provider Details

I. General information

NPI: 1093064230
Provider Name (Legal Business Name): WILLIAM MATTHEW MARTIN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON ST
BUFFALO NY
14263-0001
US

IV. Provider business mailing address

ELM AND CARLTON ST
BUFFALO NY
14263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax: 716-845-3300
Mailing address:
  • Phone: 716-845-2300
  • Fax: 716-845-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015802
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: