Basic Information
| Provider Information | |||||||||
| NPI: | 1316358609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIESNER | ||||||||
| OtherFirstName: | KAYLA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2157 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142142648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168621000 | ||||||||
| FaxNumber: | 7168621899 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142121460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165293020 | ||||||||
| FaxNumber: | 7168816247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2014 | ||||||||
| LastUpdateDate: | 07/03/2019 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 293419 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.