Provider Demographics
NPI:1063413375
Name:MANCUSO, SUSAN CARRIE (FNP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CARRIE
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1448
Mailing Address - Country:US
Mailing Address - Phone:716-885-6507
Mailing Address - Fax:
Practice Address - Street 1:3435 MAIN ST
Practice Address - Street 2:UNIVERSITY OF BUFFALO /MICHAEL HALL
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-3001
Practice Address - Country:US
Practice Address - Phone:716-829-3316
Practice Address - Fax:716-829-2564
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330754-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily