Basic Information
Provider Information | |||||||||
NPI: | 1710292982 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIEZEGA | ||||||||
FirstName: | ROCHELLE | ||||||||
MiddleName: | N. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JANESE | ||||||||
OtherFirstName: | ROCHELLE | ||||||||
OtherMiddleName: | N | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6255 SHERIDAN DR | ||||||||
Address2: | SUITE 304 | ||||||||
City: | WILLIAMSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 142214836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168578666 | ||||||||
FaxNumber: | 7166301054 | ||||||||
Practice Location | |||||||||
Address1: | 85 HIGH ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142031149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166301000 | ||||||||
FaxNumber: | 7166301348 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2010 | ||||||||
LastUpdateDate: | 09/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 014100 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.