Provider Demographics
NPI:1538482518
Name:PASIECZNIK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PASIECZNIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 SHERIDAN DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4836
Mailing Address - Country:US
Mailing Address - Phone:716-857-8666
Mailing Address - Fax:716-630-1054
Practice Address - Street 1:325 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8243
Practice Address - Country:US
Practice Address - Phone:716-630-1102
Practice Address - Fax:716-633-6507
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013964363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000506570003OtherBLUE CROSS BLUE SHIELD
1301314OtherINDEPENDENT HEALTH
NY441242008OtherRMC
NY000506570003OtherCOMMUNITY BLUE
NY16-1166492OtherEMPIRE
16-1166492OtherGHI
NY16-1166492OtherUNITED HEALTH CARE
040426001454OtherFIDELIS
NYCPS/120905-5OtherCOMPENSATION
16-1166492OtherGHI