Provider Demographics
NPI:1184624348
Name:ROOT, TALIA (PA)
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:ROOT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18 LIMESTONE DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8602
Mailing Address - Country:US
Mailing Address - Phone:716-632-1400
Mailing Address - Fax:716-632-5316
Practice Address - Street 1:18 LIMESTONE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8602
Practice Address - Country:US
Practice Address - Phone:716-632-1400
Practice Address - Fax:716-632-5316
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYMR1099882363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9512456OtherINDEPENDENT HEALTH
NY00026701401OtherUNIVERA
NYPA0290Medicare PIN
NY00026701401OtherUNIVERA