Provider Demographics
NPI:1598223984
Name:DISHMAN, MISSY GRAY (NP)
Entity type:Individual
Prefix:
First Name:MISSY
Middle Name:GRAY
Last Name:DISHMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 ORCHARD PARK RD STE C
Mailing Address - Street 2:ATT: CREDENTIALING
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1238
Mailing Address - Country:US
Mailing Address - Phone:716-674-3104
Mailing Address - Fax:716-674-0666
Practice Address - Street 1:3041 ORCHARD PARK RD STE C
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1238
Practice Address - Country:US
Practice Address - Phone:716-674-3104
Practice Address - Fax:716-674-0666
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309096363LA2200X
NY309096207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05536787Medicaid
NY309096OtherNYS LICENSE