=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407323546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. LAUREN SAMANTHA WIATROWSKI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2018
-----------------------------------------------------
Last Update Date | 11/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2475 HARLEM RD # 4558
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14225-4558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-322-5428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2475 HARLEM RD
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14225-4558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 025135
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------