Healthcare Provider Details

I. General information

NPI: 1972572691
Provider Name (Legal Business Name): ROY M SLEBODA RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 E CHAUTAUQUA ST.
MAYVILLE NY
14757-0168
US

IV. Provider business mailing address

95 E CHAUTAUQUA ST PO BOX 168
MAYVILLE NY
14757-0168
US

V. Phone/Fax

Practice location:
  • Phone: 716-753-7107
  • Fax: 716-753-7980
Mailing address:
  • Phone: 716-753-7107
  • Fax: 716-753-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003940
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: