Healthcare Provider Details

I. General information

NPI: 1417799156
Provider Name (Legal Business Name): COLIN EVAN DEANGELIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 YOUNGS RD STE 110
WILLIAMSVILLE NY
14221-2698
US

IV. Provider business mailing address

1020 YOUNGS RD STE 110
WILLIAMSVILLE NY
14221-2698
US

V. Phone/Fax

Practice location:
  • Phone: 716-961-9900
  • Fax:
Mailing address:
  • Phone: 716-961-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: