Provider Demographics
NPI:1144720947
Name:HACKFORD, CAITLIN VIRGINIA
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:VIRGINIA
Last Name:HACKFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2874 KULP RD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14057-9411
Mailing Address - Country:US
Mailing Address - Phone:716-479-5491
Mailing Address - Fax:
Practice Address - Street 1:5959 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2291
Practice Address - Country:US
Practice Address - Phone:716-260-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY022193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program