Healthcare Provider Details

I. General information

NPI: 1306297874
Provider Name (Legal Business Name): MARK EDGAR KERNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 N UNION RD
WILLIAMSVILLE NY
14221-5383
US

IV. Provider business mailing address

3925 SHERIDAN DR STE 100
AMHERST NY
14226-1738
US

V. Phone/Fax

Practice location:
  • Phone: 716-636-1470
  • Fax: 888-886-2563
Mailing address:
  • Phone: 716-250-6492
  • Fax: 716-250-6522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number019740
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: