Basic Information
| Provider Information | |||||||||
| NPI: | 1063916328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | RICHELLE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 488 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142400488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039441940 | ||||||||
| FaxNumber: | 2034024192 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 LOCKPORT OLCOTT RD | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140941128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164394248 | ||||||||
| FaxNumber: | 7164394838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 11/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 021929 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02383255 | 05 | NY | MEDICAID |