Healthcare Provider Details

I. General information

NPI: 1891112496
Provider Name (Legal Business Name): BRENT P MACZUGA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 DOAT ST
BUFFALO NY
14211-1612
US

IV. Provider business mailing address

184 BARTON ST
BUFFALO NY
14213-1573
US

V. Phone/Fax

Practice location:
  • Phone: 716-892-2775
  • Fax: 716-597-0554
Mailing address:
  • Phone: 716-881-6191
  • Fax: 716-881-6247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA056791
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: