Provider Demographics
NPI:1215183579
Name:VANDETTE, DANIELLE LYNN (PA)
Entity type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:LYNN
Last Name:VANDETTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:DANIELLE
Other - Middle Name:LYNN
Other - Last Name:KOSHOFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1120 YOUNGS ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-923-7326
Mailing Address - Fax:716-677-5255
Practice Address - Street 1:1120 YOUNGS ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-923-7326
Practice Address - Fax:716-677-5255
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03061887Medicaid
NYJ400000088Medicare UPIN