Healthcare Provider Details

I. General information

NPI: 1962623991
Provider Name (Legal Business Name): JARED MARTIN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
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

651 DELAWARE AVE
BUFFALO NY
14202-1001
US

V. Phone/Fax

Practice location:
  • Phone: 716-995-4450
  • Fax:
Mailing address:
  • Phone: 716-362-9730
  • Fax: 716-362-9729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008898-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: