Healthcare Provider Details

I. General information

NPI: 1851581797
Provider Name (Legal Business Name): MICHAEL JASON BUBAR PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3495 BAILEY AVE
BUFFALO NY
14215-1129
US

IV. Provider business mailing address

209 CHERRY ST
WILSON NY
14172-9503
US

V. Phone/Fax

Practice location:
  • Phone: 716-862-6001
  • Fax:
Mailing address:
  • Phone: 716-751-0152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011947-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: