Provider Demographics
NPI:1104355973
Name:KACZOR, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KACZOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 N BAILEY AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1206
Mailing Address - Country:US
Mailing Address - Phone:716-832-8500
Mailing Address - Fax:
Practice Address - Street 1:4955 N BAILEY AVE STE 202
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1206
Practice Address - Country:US
Practice Address - Phone:716-832-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant