Healthcare Provider Details

I. General information

NPI: 1225241557
Provider Name (Legal Business Name): EXTENDED MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 RIDGE RD SUITE 101
WEBSTER NY
14580-2410
US

IV. Provider business mailing address

6824 KNICKERBOCKER RD
ONTARIO NY
14519-9741
US

V. Phone/Fax

Practice location:
  • Phone: 585-671-4660
  • Fax: 585-671-4668
Mailing address:
  • Phone: 315-524-4049
  • Fax: 315-524-4049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number333050
License Number StateNY

VIII. Authorized Official

Name: MRS. MARY PATRICIA RYAN
Title or Position: NURSE PRACTICIONER
Credential: FNP
Phone: 585-671-4660