Provider Demographics
NPI:1184872749
Name:KSIAZEK, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KSIAZEK
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:PO BOX 5101
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-5101
Mailing Address - Country:US
Mailing Address - Phone:716-204-2273
Mailing Address - Fax:716-817-9905
Practice Address - Street 1:ELM AND CARLTON ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-1426
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant