Provider Demographics
NPI:1952395956
Name:CANNA, MARY PATRICIA (PA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:PATRICIA
Last Name:CANNA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 SOUTHWESTERN BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1209
Mailing Address - Country:US
Mailing Address - Phone:716-675-7000
Mailing Address - Fax:716-674-4630
Practice Address - Street 1:3045 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1209
Practice Address - Country:US
Practice Address - Phone:716-675-7000
Practice Address - Fax:716-674-4630
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005915-1363A00000X, 363A00000X
NY005195-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400094007Medicare PIN
NYS91699Medicare UPIN