Basic Information
| Provider Information | |||||||||
| NPI: | 1154304459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIRD-WAGNER | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | ELM AND CARLTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
| FaxNumber: | 7168457601 | ||||||||
| Practice Location | |||||||||
| Address1: | ELM AND CARLTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
| FaxNumber: | 7168457601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 01/07/2014 | ||||||||
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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 | 363LA2200X | F300235 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 01926232 | 05 | NY | MEDICAID |