Healthcare Provider Details

I. General information

NPI: 1063413375
Provider Name (Legal Business Name): SUSAN CARRIE MANCUSO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 MAIN ST UNIVERSITY OF BUFFALO /MICHAEL HALL
BUFFALO NY
14214-3001
US

IV. Provider business mailing address

720 LAFAYETTE AVE
BUFFALO NY
14222-1448
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-3316
  • Fax: 716-829-2564
Mailing address:
  • Phone: 716-885-6507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF330754-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: