Provider Demographics
NPI:1265517239
Name:SCHRADER, MARIETTA (ANP)
Entity type:Individual
Prefix:MRS
First Name:MARIETTA
Middle Name:
Last Name:SCHRADER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 GAFFNEY RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5536
Mailing Address - Country:US
Mailing Address - Phone:716-434-4957
Mailing Address - Fax:
Practice Address - Street 1:702 DAVISON RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5371
Practice Address - Country:US
Practice Address - Phone:716-514-9355
Practice Address - Fax:716-201-1630
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303221363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01000215Medicaid
NYP34916Medicare UPIN
NY01000215Medicaid