Provider Demographics
NPI:1366406134
Name:BURROUGHS, AMY-JO LAVAY (PAC)
Entity type:Individual
Prefix:MS
First Name:AMY-JO
Middle Name:LAVAY
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SCHOOL STREET
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GOWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14070-1133
Mailing Address - Country:US
Mailing Address - Phone:716-241-7067
Mailing Address - Fax:716-241-7197
Practice Address - Street 1:1 SCHOOL ST
Practice Address - Street 2:SUITE 107
Practice Address - City:GOWANDA
Practice Address - State:NY
Practice Address - Zip Code:14070-1133
Practice Address - Country:US
Practice Address - Phone:716-241-7067
Practice Address - Fax:716-241-7197
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02626126Medicaid
NY6209596955OtherDEPARTMENT OF TRANSPORTATION
NYPA0806Medicare PIN
NYQ23408Medicare UPIN
NYPA0806Medicare ID - Type Unspecified