Basic Information
| Provider Information | |||||||||
| NPI: | 1477707198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T., D.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACOBS | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.T., D.P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3085 HARLEM ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445000 | ||||||||
| FaxNumber: | 7168445050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3085 HARLEM ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142252591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168445000 | ||||||||
| FaxNumber: | 7168445050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2008 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 030475-NG | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 030475-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1477707198 | 01 | NY | UNIVERA | OTHER | 9315468 | 01 | NY | INDEPENDENT HEALTH | OTHER | 11303 | 01 | NY | AETNA/MAGNCARE | OTHER | 000531015001 | 01 | NY | BLUE CROSS WNY | OTHER | 1053747 | 01 | NY | GHI | OTHER | 1477707198 | 01 | NY | NOVA | OTHER |