Provider Demographics
NPI:1740381946
Name:HEFTKA, KELLIE E (PA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:E
Last Name:HEFTKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:E
Other - Last Name:KRAWCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:120 GARDENVILLE PKWY W
Mailing Address - Street 2:ATTN: BETTY PICCILLO
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1324
Mailing Address - Country:US
Mailing Address - Phone:716-857-6150
Mailing Address - Fax:716-656-4074
Practice Address - Street 1:120 GARDENVILLE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1324
Practice Address - Country:US
Practice Address - Phone:716-668-3600
Practice Address - Fax:716-656-4274
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011382363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY190433DLOtherPREFERRED CARE #
NY000528804001OtherHEALTH NOW BCBS #
NY070111000100OtherFIDELIS CARE # AU
NY070111000099OtherFIDELIS CARE # SD
NY9514067OtherIHA #