Healthcare Provider Details

I. General information

NPI: 1740381946
Provider Name (Legal Business Name): KELLIE E HEFTKA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE E KRAWCZYK PA

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 GARDENVILLE PKWY W
WEST SENECA NY
14224-1324
US

IV. Provider business mailing address

120 GARDENVILLE PKWY W ATTN: BETTY PICCILLO
WEST SENECA NY
14224-1324
US

V. Phone/Fax

Practice location:
  • Phone: 716-668-3600
  • Fax: 716-656-4274
Mailing address:
  • Phone: 716-857-6150
  • Fax: 716-656-4074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011382
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: