Healthcare Provider Details

I. General information

NPI: 1275498628
Provider Name (Legal Business Name): LYDIA MARIE WISHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 ELM ST
BUFFALO NY
14203-1104
US

IV. Provider business mailing address

ELM AND CARLTON ST
BUFFALO NY
14263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 716-341-5504
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number312201-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number312201-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: