Provider Demographics
NPI:1407852973
Name:KIRK, ALLYSON LAETITA (RPA-C)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:LAETITA
Last Name:KIRK
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CORPORATE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1263
Mailing Address - Country:US
Mailing Address - Phone:716-631-0380
Mailing Address - Fax:716-631-3229
Practice Address - Street 1:500 CORPORATE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1263
Practice Address - Country:US
Practice Address - Phone:716-631-0380
Practice Address - Fax:716-631-3229
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006458-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02504929Medicaid
NYPA0002Medicare ID - Type Unspecified