Provider Demographics
NPI:1497770093
Name:WOLAK, ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:
Last Name:WOLAK
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 1:14 KENNEDY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1435
Mailing Address - Country:US
Mailing Address - Phone:607-756-9941
Mailing Address - Fax:607-753-3204
Practice Address - Street 1:14 KENNEDY PARKWAY
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1435
Practice Address - Country:US
Practice Address - Phone:607-756-9941
Practice Address - Fax:607-756-2907
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01286039Medicaid
NY01286039Medicaid
S05707Medicare UPIN