Provider Demographics
NPI:1427430388
Name:WASACZ, MEAGAN ADELL (PA-C)
Entity type:Individual
Prefix:
First Name:MEAGAN
Middle Name:ADELL
Last Name:WASACZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEAGAN
Other - Middle Name:
Other - Last Name:POTRATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:2435 6TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-274-5143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018763363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid
NY01420795Medicaid