1164736526 NPI number — MRS. CHRISTINA LYNN SOBCZAK PNP

Table of content: MRS. CHRISTINA LYNN SOBCZAK PNP (NPI 1164736526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164736526 NPI number — MRS. CHRISTINA LYNN SOBCZAK PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOBCZAK
Provider First Name:
CHRISTINA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LACKEMEYER
Provider Other First Name:
CHRISTINA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164736526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
860 MAIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORFU
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14036-9753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-599-6446
Provider Business Mailing Address Fax Number:
585-599-3166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 MAIN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORFU
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14036-9753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-599-6446
Provider Business Practice Location Address Fax Number:
585-599-6446
Provider Enumeration Date:
07/28/2010

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: 163W00000X , with the licence number:  543559-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 382152 , 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: 03254235 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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