Provider Demographics
NPI:1194745802
Name:FAZEKAS, PAUL L (PHD, NP)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:FAZEKAS
Suffix:
Gender:M
Credentials:PHD, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WASHINGTON ST
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1711
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:465 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:N TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-6941
Practice Address - Country:US
Practice Address - Phone:716-694-7749
Practice Address - Fax:716-694-0793
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYOF400720363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00030241505OtherUNIVERA
NY000500587004OtherCOMMUNITY BLUE
NYR53903Medicare UPIN
NY000500587004OtherCOMMUNITY BLUE