Healthcare Provider Details

I. General information

NPI: 1164128013
Provider Name (Legal Business Name): NICOLE ELISE TSCHIDERER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 W STATE RD
SAINT BONAVENTURE NY
14778-9800
US

IV. Provider business mailing address

3261 W STATE RD
SAINT BONAVENTURE NY
14778-9800
US

V. Phone/Fax

Practice location:
  • Phone: 716-375-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032282-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: