Provider Demographics
NPI:1437140423
Name:REDLECKI, STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:REDLECKI
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 1:95 E CHAUTAUQUA ST
Mailing Address - Street 2:PO BOX 168
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-0168
Mailing Address - Country:US
Mailing Address - Phone:716-753-7107
Mailing Address - Fax:716-753-5367
Practice Address - Street 1:95 E CHAUTAUQUA ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:14757-0168
Practice Address - Country:US
Practice Address - Phone:716-753-7107
Practice Address - Fax:716-753-5367
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008740363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP70728Medicare UPIN
NYPA0929Medicare ID - Type Unspecified