Healthcare Provider Details

I. General information

NPI: 1205975232
Provider Name (Legal Business Name): LISA MARIE FORESTAL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE WELLER

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGH ST
BUFFALO NY
14203-1126
US

IV. Provider business mailing address

3435 MAIN ST HAYES A
BUFFALO NY
14214-3001
US

V. Phone/Fax

Practice location:
  • Phone: 716-859-1254
  • Fax: 716-859-4586
Mailing address:
  • Phone: 716-829-3670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011316
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: