MEDICARE: MRS. LARA A CONNELLY MS, RPAC

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	010777-1	NY

General Provider Information

NPI Number	:	1598751455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LARA A CONNELLY MS, RPAC

Provider Business Mailing Address
First Line	:	108 COLONIAL AVE
Second Line	:
City	:	KENMORE
State	:	NY
Zip	:	14217-1156
Country	:	US
Telephone Number	:	716-523-2090
Fax Number	:

Provider Business Practice Location Address
First Line	:	219 BRYANT ST
Second Line	:	DEPT OF NEONATOLOGY
City	:	BUFFALO
State	:	NY
Zip	:	14222-2006
Country	:	US
Telephone Number	:	716-878-7000
Fax Number	:

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

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	04/24/2014

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