Basic Information
| Provider Information | |||||||||
| NPI: | 1083090294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHALEN | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 YOUNGS RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166367990 | ||||||||
| FaxNumber: | 7166367992 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 E ROBINSON RD STE 207 | ||||||||
| Address2: | |||||||||
| City: | WEST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165641111 | ||||||||
| FaxNumber: | 7169290194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2015 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 018806-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 04310601 | 05 | NY | MEDICAID |