Healthcare Provider Details

I. General information

NPI: 1366406134
Provider Name (Legal Business Name): AMY-JO LAVAY BURROUGHS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SCHOOL ST SUITE 107
GOWANDA NY
14070-1133
US

IV. Provider business mailing address

1 SCHOOL STREET SUITE 107
GOWANDA NY
14070-1133
US

V. Phone/Fax

Practice location:
  • Phone: 716-241-7067
  • Fax: 716-241-7197
Mailing address:
  • Phone: 716-241-7067
  • Fax: 716-241-7197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010035
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: