=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679547582
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD P MYERS PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3495 BAILEY AVE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14215-1129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-834-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10986 NEW OREGON RD
-----------------------------------------------------
City | NORTH COLLINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14111-9791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-337-0158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 000795
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------