Provider Demographics
NPI:1396006425
Name:DEITZER, REBECCA (RPA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:DEITZER
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:SEWASTYNOWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:ELM AND CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14263-0001
Mailing Address - Country:US
Mailing Address - Phone:716-845-2300
Mailing Address - Fax:716-845-3423
Practice Address - Street 1:ELM AND CARLTON STREETS
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-0001
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:716-845-3423
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant