MEDICARE: MARY LOU DECKER PA

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	363AM0700X	Medical Physician Assistant	0003041-1	NY

General Provider Information

NPI Number	:	1528180080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOU DECKER PA

Provider Business Mailing Address
First Line	:	964 DELAWARE AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14209-1806
Country	:	US
Telephone Number	:	716-863-0196
Fax Number	:

Provider Business Practice Location Address
First Line	:	964 DELAWARE AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14209-1806
Country	:	US
Telephone Number	:	716-863-0196
Fax Number	:

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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