Basic Information
| Provider Information | |||||||||
| NPI: | 1154661080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNOW | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD STE 208 | ||||||||
| Address2: | |||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 38 WATER ST | ||||||||
| Address2: | |||||||||
| City: | CUBA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147271023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859684137 | ||||||||
| FaxNumber: | 5859689587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2013 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA059009 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103443113 | 05 | PA | MEDICAID |