Healthcare Provider Details

I. General information

NPI: 1134757438
Provider Name (Legal Business Name): LAUREN MARIE FICKETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 EXCHANGE ST STE 710
BUFFALO NY
14210-1464
US

IV. Provider business mailing address

2508 SPRING LAKE BLVD
PAINESVILLE OH
44077-4914
US

V. Phone/Fax

Practice location:
  • Phone: 716-852-4772
  • Fax:
Mailing address:
  • Phone: 716-982-6910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024912
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: