Provider Demographics
NPI:1750682894
Name:ZELESNIKAR, KACY L (PA)
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:L
Last Name:ZELESNIKAR
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 1:415 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-4925
Mailing Address - Country:US
Mailing Address - Phone:607-785-2460
Mailing Address - Fax:607-785-2584
Practice Address - Street 1:415 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-4925
Practice Address - Country:US
Practice Address - Phone:607-785-2460
Practice Address - Fax:607-785-2584
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
J400042216Medicare PIN