Healthcare Provider Details

I. General information

NPI: 1144053364
Provider Name (Legal Business Name): MOIRA GRACE ANTALEK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N MAPLEMERE RD STE 120
WILLIAMSVILLE NY
14221-3181
US

IV. Provider business mailing address

111 N MAPLEMERE RD STE 120
WILLIAMSVILLE NY
14221-3181
US

V. Phone/Fax

Practice location:
  • Phone: 716-836-4646
  • Fax: 716-836-4696
Mailing address:
  • Phone: 716-836-4646
  • Fax: 716-836-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036480
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: