Individual
MARK ALAN MEDAKOVICH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
ELM AND CARLTON STREETS, BUFFALO, NY 14263-1104
(716) 845-2300
Mailing address
16 KETCHUM PL, BUFFALO, NY 14213-2661
(716) 870-9108
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
647277
NY
367500000X
Certified Registered Nurse Anesthetist
Primary
647277
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
647277
NYS LICENSE
NY
Enumeration date
03/20/2019
Last updated
01/21/2021
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