Healthcare Provider Details

I. General information

NPI: 1114567518
Provider Name (Legal Business Name): MEGAN WREST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 LA RIVIERE DR STE 140
BUFFALO NY
14202-4306
US

IV. Provider business mailing address

671 FULTON ST
BUFFALO NY
14210-1459
US

V. Phone/Fax

Practice location:
  • Phone: 716-893-1010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024598-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: