Provider Demographics
NPI:1386871572
Name:WALCZAK, AMANDA L (RPA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:KULCZYK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:3900 N BUFFALO ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1842
Practice Address - Country:US
Practice Address - Phone:716-656-4988
Practice Address - Fax:716-817-1719
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NY013291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical