Healthcare Provider Details

I. General information

NPI: 1811391584
Provider Name (Legal Business Name): MARK AZZARELLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3176 ABBOTT RD BUILDING A, SUITE 500
ORCHARD PARK NY
14127-1069
US

IV. Provider business mailing address

3176 ABBOTT RD BUILDING A, SUITE 500
ORCHARD PARK NY
14127-1069
US

V. Phone/Fax

Practice location:
  • Phone: 716-822-2177
  • Fax: 716-822-8165
Mailing address:
  • Phone: 716-822-2177
  • Fax: 716-822-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22 500058
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: