Provider Demographics
NPI:1558005264
Name:RUTZ, MARYANNE WAUGH
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:WAUGH
Last Name:RUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANNE
Other - Last Name:RUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 WOODWARD DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3532
Mailing Address - Country:US
Mailing Address - Phone:785-640-8252
Mailing Address - Fax:
Practice Address - Street 1:2950 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14217-1304
Practice Address - Country:US
Practice Address - Phone:785-640-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY766207367500000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist