Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | NY5166 | NY |
NPI | 1003029752 |
---|---|
Provider Name | Mary Lee |
First Address | Tonawanda, NY 14150-6406 |
Second Address | Buffalo, NY 14202-1403 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2007 |
Last Update Date | 08/07/2007 |