Basic Information
| Provider Information | |||||||||
| NPI: | 1073550703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIOMEK | ||||||||
| FirstName: | PAULETTE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367163202 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 FOOTE AVE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164870141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-06662 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 010658-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02712783 | 05 | NY | MEDICAID |