=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932114642
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMEY R DZIULKO PHYSICIAN ASSISTANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 08/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HIGH STREET SECTION B-2
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-710-8266
-----------------------------------------------------
Fax | 716-710-8267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 908 NIAGARA FALLS BLVD SUITE 208
-----------------------------------------------------
City | NORTH TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-692-2160
-----------------------------------------------------
Fax | 716-213-0935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 006624-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------