Healthcare Provider Details

I. General information

NPI: 1497162754
Provider Name (Legal Business Name): ANN S. REGER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 BRYANT ST
BUFFALO NY
14222-2006
US

IV. Provider business mailing address

2157 MAIN ST
BUFFALO NY
14214-2692
US

V. Phone/Fax

Practice location:
  • Phone: 716-878-7673
  • Fax: 716-878-7945
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017611-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: