Basic Information
| Provider Information | |||||||||
| NPI: | 1346432333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUCZMANSKI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 ESSJAY RD | ||||||||
| Address2: | STE 170 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301219 | ||||||||
| FaxNumber: | 7168171726 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 ESSJAY RD STE 170 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166312517 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 011966 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 00028138901 | 01 | NY | UNIVERA | OTHER | 02908845 | 05 | NY | MEDICAID | 9514276 | 01 | NY | INDEPENDENT HEALTH | OTHER | 000529486001 | 01 | NY | HEALTH NOW | OTHER |