Healthcare Provider Details

I. General information

NPI: 1568627339
Provider Name (Legal Business Name): JAIME FETES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 HARLEM RD STE 200
CHEEKTOWAGA NY
14225-2563
US

IV. Provider business mailing address

3085 HARLEM RD SUITE 350
CHEEKTOWAGA NY
14225-2591
US

V. Phone/Fax

Practice location:
  • Phone: 716-844-5000
  • Fax:
Mailing address:
  • Phone: 716-844-5500
  • Fax: 716-844-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number012630-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: