Provider Demographics
NPI:1285186320
Name:CZWOJDAK, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CZWOJDAK
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 1:135 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-2736
Mailing Address - Country:US
Mailing Address - Phone:716-375-7500
Mailing Address - Fax:
Practice Address - Street 1:88 E TIOGA AVE STE 102
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2882
Practice Address - Country:US
Practice Address - Phone:607-684-6115
Practice Address - Fax:607-684-6120
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020282363A00000X
NY020282-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant