Provider Demographics
NPI:1972830511
Name:CZAJKOWSKI, HEIDI M (PA)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:M
Last Name:CZAJKOWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:M
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:239 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1228
Mailing Address - Country:US
Mailing Address - Phone:315-592-0721
Mailing Address - Fax:315-598-4733
Practice Address - Street 1:522 S 4TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2946
Practice Address - Country:US
Practice Address - Phone:315-598-4790
Practice Address - Fax:315-598-4719
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013632363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02997217Medicaid
NYJ400008343Medicare PIN