Healthcare Provider Details

I. General information

NPI: 1194745802
Provider Name (Legal Business Name): PAUL L. FAZEKAS PH.D, N.P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 PAYNE AVE
N TONAWANDA NY
14120-6941
US

IV. Provider business mailing address

525 WASHINGTON ST MANAGED CARE DEPARTMENT
BUFFALO NY
14203-1711
US

V. Phone/Fax

Practice location:
  • Phone: 716-694-7749
  • Fax: 716-694-0793
Mailing address:
  • Phone: 716-856-4494
  • Fax: 716-842-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberOF400720
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: