Basic Information
Provider Information | |||||||||
NPI: | 1346675204 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RE | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | ELOISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | ASHLEY | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RPA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 818 ELLICOTT ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142031021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163232000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 818 ELLICOTT ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142031021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163232000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2013 | ||||||||
LastUpdateDate: | 11/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 016899 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 03746325 | 05 | NY |   | MEDICAID | 150624000031 | 01 | NY | FIDELIS | OTHER | PAR | 01 | NY | BC OF WNY | OTHER | PAR | 01 | NY | YOURCARE | OTHER | 00026794502 | 01 | NY | UNIVERA | OTHER |