Provider Demographics
NPI:1386886299
Name:MOORE, MARY BETH (AGNP-C)
Entity type:Individual
Prefix:MRS
First Name:MARY BETH
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:MARY BETH
Other - Middle Name:
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:100 COLLEGE PKWY
Mailing Address - Street 2:STE 260
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6800
Mailing Address - Country:US
Mailing Address - Phone:716-868-2252
Mailing Address - Fax:
Practice Address - Street 1:701 SENECA ST STE 646C
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-1351
Practice Address - Country:US
Practice Address - Phone:716-995-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY605481163W00000X
NYF307188-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1386886299OtherNPI