Provider Demographics
NPI:1871184424
Name:ILLUMINATE NP PSYCHIATRY
Entity Type:Organization
Organization Name:ILLUMINATE NP PSYCHIATRY
Other - Org Name:ILLUMINATE NP PSYCHIATRY, PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTARSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-903-6036
Mailing Address - Street 1:3055 SOUTHWESTERN BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1231
Mailing Address - Country:US
Mailing Address - Phone:716-903-6036
Mailing Address - Fax:716-463-2225
Practice Address - Street 1:3055 SOUTHWESTERN BLVD STE 110
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1231
Practice Address - Country:US
Practice Address - Phone:716-903-6036
Practice Address - Fax:716-463-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-27
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05703237Medicaid