Healthcare Provider Details

I. General information

NPI: 1184872749
Provider Name (Legal Business Name): NICOLE KSIAZEK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON ST
BUFFALO NY
14263-1426
US

IV. Provider business mailing address

PO BOX 5101
BUFFALO NY
14240-5101
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax:
Mailing address:
  • Phone: 716-204-2273
  • Fax: 716-817-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012647
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: