Provider Demographics
NPI:1548632839
Name:VANDERMARK, LESLEY WILLIS (PHD, ATC)
Entity type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:WILLIS
Last Name:VANDERMARK
Suffix:
Gender:F
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CARRIAGE HL W
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2103
Mailing Address - Country:US
Mailing Address - Phone:814-558-1788
Mailing Address - Fax:
Practice Address - Street 1:29 CARRIAGE HL W
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14221-2103
Practice Address - Country:US
Practice Address - Phone:814-558-1788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004262-012255A2300X
CT0006662081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer