Basic Information
| Provider Information | |||||||||
| NPI: | 1083670293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANEY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FETZER | ||||||||
| OtherFirstName: | MARY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 2931 MILITARY RD | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143041251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162984869 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 334029 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02505782 | 05 | NY | MEDICAID |