Basic Information
| Provider Information | |||||||||
| NPI: | 1134757438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FICKETT | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2508 SPRING LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440774914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169826910 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 726 EXCHANGE ST STE 710 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142101464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168524772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2020 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 024912 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.