Basic Information
| Provider Information | |||||||||
| NPI: | 1851377154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARIEN | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RPA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 ORCHARD PARK RD | ||||||||
| Address2: | STE A105 | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142242646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166776000 | ||||||||
| FaxNumber: | 7166776006 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 PARK CLUB LN | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168399402 | ||||||||
| FaxNumber: | 7168393570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 006802 1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 00026522501 | 01 | UNIVERA HEALTHCARE | OTHER | 9511989 | 01 | NY | INDEPENDENT HEALTH | OTHER | 02107399 | 05 | NY | MEDICAID | 000570154002 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER |