Basic Information
| Provider Information | |||||||||
| NPI: | 1972572691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLEBODA | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 E CHAUTAUQUA ST | ||||||||
| Address2: | PO BOX 168 | ||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167537980 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 E CHAUTAUQUA ST. | ||||||||
| Address2: | |||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167537980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003940 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9512028 | 01 | NY | INDEPENDENT HEALTH | OTHER | 00026498502 | 01 | NY | UNIVERA | OTHER | 000570065003 | 01 | NY | BCBSWNY | OTHER | 01594765 | 05 | NY | MEDICAID |