Basic Information
| Provider Information | |||||||||
| NPI: | 1518113380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEDNAREK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JORDAN | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | SUZANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | 5344 SACANDAGA RD. | ||||||||
| City: | GALWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120740190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188826955 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5344 SACANDAGA RD. | ||||||||
| Address2: | |||||||||
| City: | GALWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188826955 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 11/04/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 338015 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.