Provider Demographics
NPI:1316339088
Name:DELA CRUZ, MAICA PUNZALAN (PA)
Entity type:Individual
Prefix:
First Name:MAICA
Middle Name:PUNZALAN
Last Name:DELA CRUZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 SHERIDAN DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4836
Mailing Address - Country:US
Mailing Address - Phone:716-630-2587
Mailing Address - Fax:716-857-8944
Practice Address - Street 1:2850 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1494
Practice Address - Country:US
Practice Address - Phone:503-666-5050
Practice Address - Fax:503-666-1162
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018490363A00000X, 363AM0700X
ORPA188907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY018490OtherNEW YORK STATE LICENSE NUMBER