Basic Information
Provider Information
NPI: 1003139007
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DOMON
FirstName: SUSAN
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: PA
OtherOrganizationName:  
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OtherCredential:  
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Mailing Information
Address1: 17 SEGSBURY RD
Address2:  
City: WILLIAMSVILLE
State: NY
PostalCode: 142213407
CountryCode: US
TelephoneNumber: 5855070847
FaxNumber:  
Practice Location
Address1: 1 JOHN JAMES AUDUBON PKWY
Address2:  
City: AMHERST
State: NY
PostalCode: 142281145
CountryCode: US
TelephoneNumber: 7162044500
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/04/2010
LastUpdateDate: 01/30/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X013898NYY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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