Provider Demographics
NPI:1346432333
Name:KUCZMANSKI, MARK R (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:KUCZMANSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD
Mailing Address - Street 2:STE 170
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5782
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:325 ESSJAY RD STE 170
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8243
Practice Address - Country:US
Practice Address - Phone:716-631-2517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011966363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00028138901OtherUNIVERA
NY02908845Medicaid
NY9514276OtherINDEPENDENT HEALTH
NY000529486001OtherHEALTH NOW
NY00028138901OtherUNIVERA