Basic Information
| Provider Information | |||||||||
| NPI: | 1912954900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEA | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5007 TRANSIT RD | ||||||||
| Address2: | |||||||||
| City: | DEPEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140434617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162044500 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Practice Location | |||||||||
| Address1: | 2157 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142142648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162044500 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 03/23/2015 | ||||||||
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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 | 207PE0004X | 005534-1 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 02354272 | 05 | NY | MEDICAID |