Provider Demographics
NPI:1407129109
Name:SZKUTAK, ANGEL M (PA)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:M
Last Name:SZKUTAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 ERIE RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9430
Mailing Address - Country:US
Mailing Address - Phone:716-947-0408
Mailing Address - Fax:
Practice Address - Street 1:7060 ERIE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9430
Practice Address - Country:US
Practice Address - Phone:716-947-0408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-12
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01632562Medicaid
NYJ400066514Medicare Oscar/Certification