Healthcare Provider Details

I. General information

NPI: 1528973427
Provider Name (Legal Business Name): CARLY WICKA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 N BUFFALO ST
ORCHARD PARK NY
14127-1842
US

IV. Provider business mailing address

425 ESSJAY RD STE 170
WILLIAMSVILLE NY
14221-8235
US

V. Phone/Fax

Practice location:
  • Phone: 716-656-4804
  • Fax: 716-250-5933
Mailing address:
  • Phone: 716-630-1219
  • Fax: 716-817-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number036685
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: