Healthcare Provider Details

I. General information

NPI: 1659613073
Provider Name (Legal Business Name): MARC CHRISTOPHER MOYER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2013
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SENECA ST STE 646C
BUFFALO NY
14210-1351
US

IV. Provider business mailing address

11522 BOLTON RD
SPRINGVILLE NY
14141-9503
US

V. Phone/Fax

Practice location:
  • Phone: 716-995-4450
  • Fax:
Mailing address:
  • Phone: 716-200-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number016541-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: