MEDICARE: LEIDA PAGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	239014-1	NY

General Provider Information

NPI Number	:	1124359948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEIDA PAGAN

Provider Business Mailing Address
First Line	:	260 INDIAN CHURCH RD
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14210-1944
Country	:	US
Telephone Number	:	716-446-3983
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 INDIAN CHURCH RD
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14210-1944
Country	:	US
Telephone Number	:	716-446-3983
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2010
Last Update Date	:	01/18/2010

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