1154398055 NPI number — HAK J KO MD

Table of content: MRS. CARMEN RENEE WYCOFF RN, MSN, ARNP (NPI 1053645291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154398055 NPI number — HAK J KO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KO
Provider First Name:
HAK
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154398055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5687 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-5517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-204-3541
Provider Business Mailing Address Fax Number:
716-204-3542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5687 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
WILLIAMSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14221-5517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-204-3541
Provider Business Practice Location Address Fax Number:
716-204-3542
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  137567 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00020222401 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1509258 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00508010006 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00685534 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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