Provider Demographics
NPI:1326030495
Name:WIKTOR, KYLE ANDREW (NP)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:ANDREW
Last Name:WIKTOR
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SENECA ST STE 646C
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210-1351
Mailing Address - Country:US
Mailing Address - Phone:716-995-4450
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1025
Practice Address - Country:US
Practice Address - Phone:585-786-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333603-1363LF0000X
NYF401552363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03232620Medicaid