=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306803168
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGO VILLAGOMEZ NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 09/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 S ELMWOOD AVE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14201-2361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-855-1099
-----------------------------------------------------
Fax | 716-855-1310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 93 N RYAN ST
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14210-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-855-1099
-----------------------------------------------------
Fax | 716-855-1310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | F-380696
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------