Provider Demographics
NPI:1750534822
Name:KASPEREK, AMY LYNN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LYNN
Last Name:KASPEREK
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:COOMBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-452-2333
Mailing Address - Fax:315-452-2336
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 1C
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2333
Practice Address - Fax:315-452-2336
Is Sole Proprietor?:No
Enumeration Date:2008-11-02
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053578363AM0700X
NY012899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03486808Medicaid
NYJ400062901Medicare PIN