Provider Demographics
NPI:1386601110
Name:NIEDERPRUEM, MARY SUSAN (ANP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUSAN
Last Name:NIEDERPRUEM
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:SLOPKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:1150 YOUNGS RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-636-7990
Mailing Address - Fax:716-636-7993
Practice Address - Street 1:1150 YOUNGS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-636-7979
Practice Address - Fax:716-636-7993
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301068363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS27138Medicare UPIN