Provider Demographics
NPI:1568413102
Name:WYSOCKI, GARY C (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:C
Last Name:WYSOCKI
Suffix:
Gender:M
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 1:397 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-2275
Mailing Address - Country:US
Mailing Address - Phone:716-847-6610
Mailing Address - Fax:
Practice Address - Street 1:397 LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14204-2275
Practice Address - Country:US
Practice Address - Phone:716-847-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00057036602OtherBLUE CROSS BLUE SHIELD HEALTH NOW
NY9514132OtherINDEPENDENT HEALTH
NY00027974001OtherUNIVERA HEALTH
NY070515000056OtherFIDELIS
NY9514132OtherINDEPENDENT HEALTH