Provider Demographics
NPI:1639107196
Name:BUCZKOWSKI, GLENN ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ROBERT
Last Name:BUCZKOWSKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4927 MAIN ST
Mailing Address - Street 2:STE 400
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4081
Mailing Address - Country:US
Mailing Address - Phone:716-690-2691
Mailing Address - Fax:716-690-2695
Practice Address - Street 1:4927 MAIN ST
Practice Address - Street 2:STE 400
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-4081
Practice Address - Country:US
Practice Address - Phone:716-877-7000
Practice Address - Fax:716-322-1164
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006921363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS9487Medicare UPIN