Basic Information
| Provider Information | |||||||||
| NPI: | 1649513730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COE | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BYCZYNSKI | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 77 GOODELL STREET | ||||||||
| Address2: | STE 240 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166459694 | ||||||||
| FaxNumber: | 7188456699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2465 SHERIDAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141509407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168359800 | ||||||||
| FaxNumber: | 7168359888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 016474 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 016474-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 03573104 | 05 | NY | MEDICAID |