Provider Demographics
NPI:1700874146
Name:WILCZANSKI, PETER LUKASZ (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:LUKASZ
Last Name:WILCZANSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:717 STATE ST
Mailing Address - Street 2:SUITE 16
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1341
Mailing Address - Country:US
Mailing Address - Phone:814-480-7100
Mailing Address - Fax:814-480-7604
Practice Address - Street 1:5241 BUFFALO RD
Practice Address - Street 2:LAKESHORE FAMILY PRACTICE
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-2309
Practice Address - Country:US
Practice Address - Phone:814-877-7686
Practice Address - Fax:814-877-7692
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD040751L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00025573901OtherUNIVERA
PA0011180320003Medicaid
PA080081947OtherRR MEDICARE
PA66429OtherUNISON
PAP000383OtherGATEWAY
PA212709OtherUPMC
PA522615OtherAETNA
NY01917019OtherNY MEDICAID
PA015973OtherBLUE SHIELD
NY01917019OtherNY MEDICAID
PA212709OtherUPMC