Provider Demographics
NPI:1184033557
Name:PANKIEWICZ, LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PANKIEWICZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MAPLE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2917
Mailing Address - Country:US
Mailing Address - Phone:716-626-5250
Mailing Address - Fax:716-626-5345
Practice Address - Street 1:60 MAPLE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2917
Practice Address - Country:US
Practice Address - Phone:716-626-5250
Practice Address - Fax:716-626-5345
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017648-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03966630Medicaid