Basic Information
| Provider Information | |||||||||
| NPI: | 1598223984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISHMAN | ||||||||
| FirstName: | MISSY | ||||||||
| MiddleName: | GRAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | ELM AND CARLTON STREETS | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
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| Practice Location | |||||||||
| Address1: | ELM AND CARLTON STREETS | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2019 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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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 | 363L00000X | 309096 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207QA0505X | 309096 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 309096 | 01 | NY | NYS LICENSE | OTHER |