Provider Demographics
NPI:1053161521
Name:SLATE, JUSTIN DOMINIC FRANCIS (MB BCH BAO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DOMINIC FRANCIS
Last Name:SLATE
Suffix:
Gender:M
Credentials:MB BCH BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217
Mailing Address - Country:US
Mailing Address - Phone:716-465-6630
Mailing Address - Fax:
Practice Address - Street 1:77 GOODELL ST.
Practice Address - Street 2:SUITE 340 EMERGENCY MEDICINE
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203
Practice Address - Country:US
Practice Address - Phone:716-645-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program