Provider Demographics
NPI:1376798520
Name:WOJTASIEWICZ, AGATA (MD)
Entity Type:Individual
Prefix:
First Name:AGATA
Middle Name:
Last Name:WOJTASIEWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5112 WEST TAFT ROAD
Mailing Address - Street 2:SUITE L
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-452-2500
Mailing Address - Fax:315-452-2510
Practice Address - Street 1:8278 WILLETT PARKWAY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027
Practice Address - Country:US
Practice Address - Phone:315-652-1325
Practice Address - Fax:315-857-2886
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY259755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03308270Medicaid
NYJ400045701Medicare PIN
NYJ400038762Medicare PIN