Healthcare Provider Details

I. General information

NPI: 1083286025
Provider Name (Legal Business Name): MICHAEL REPICKY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2021
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 WELLNESS WAY STE 111
LATHAM NY
12110-2156
US

IV. Provider business mailing address

6 WELLNESS WAY STE 201
LATHAM NY
12110-2156
US

V. Phone/Fax

Practice location:
  • Phone: 518-213-0227
  • Fax: 518-782-3816
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027521
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: