Healthcare Provider Details

I. General information

NPI: 1275512220
Provider Name (Legal Business Name): THOMAS G MALANOWSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 ERIE ST
LITTLE VALLEY NY
14755-1011
US

IV. Provider business mailing address

610 WAYNE ST
OLEAN NY
14760-2355
US

V. Phone/Fax

Practice location:
  • Phone: 716-938-9666
  • Fax: 716-938-9668
Mailing address:
  • Phone: 716-372-1570
  • Fax: 716-373-2096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000453-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: