Healthcare Provider Details

I. General information

NPI: 1285186320
Provider Name (Legal Business Name): JACQUELINE CZWOJDAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 E TIOGA AVE STE 102
CORNING NY
14830-2882
US

IV. Provider business mailing address

135 N UNION ST
OLEAN NY
14760-2736
US

V. Phone/Fax

Practice location:
  • Phone: 607-684-6115
  • Fax: 607-684-6120
Mailing address:
  • Phone: 716-375-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020282
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number020282-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: