Provider Demographics
NPI:1114688520
Name:GRZEGORSKI, JOSEPH ARTHUR (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ARTHUR
Last Name:GRZEGORSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3753 WALWORTH RD
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:NY
Mailing Address - Zip Code:14568
Mailing Address - Country:US
Mailing Address - Phone:860-391-5333
Mailing Address - Fax:
Practice Address - Street 1:1200 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1090
Practice Address - Country:US
Practice Address - Phone:860-391-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY028218363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant