Basic Information
| Provider Information | |||||||||
| NPI: | 1366547440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIATROWSKI | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2770 HOPKINS RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142281411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165803805 | ||||||||
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| Practice Location | |||||||||
| Address1: | 692 MILLERSPORT HIGHWAY | ||||||||
| Address2: | MILLERSPORT & PHYSICAL THERAPY | ||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168399529 | ||||||||
| FaxNumber: | 7168392722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 12/17/2010 | ||||||||
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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 | 225100000X | 011595 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 00011283007 | 01 | NY | UNIVERA LEGACY# | OTHER | 000626050003 | 01 | NY | HEALTH NOW BCBS LEGACY# | OTHER | 08494418 | 05 | NY | MEDICAID | 159888FT | 01 | NY | PREFERRED CARE LEGACY# | OTHER | 9390555 | 01 | NY | IHA LEGACY# | OTHER | 000000113334 | 01 | NY | GHI HMO LEGACY# | OTHER | 050301000137 | 01 | NY | FIDELIS LEGACY# | OTHER |