Healthcare Provider Details

I. General information

NPI: 1295464766
Provider Name (Legal Business Name): TINA WHEATON ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 DELAWARE AVE
BUFFALO NY
14202-3913
US

IV. Provider business mailing address

80 SPRUCEWOOD DR
CHEEKTOWAGA NY
14227-3224
US

V. Phone/Fax

Practice location:
  • Phone: 716-858-7618
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number310712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: