Provider Demographics
NPI:1477437846
Name:SEELBACH, JACK MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MATTHEW
Last Name:SEELBACH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-1421
Mailing Address - Country:US
Mailing Address - Phone:716-345-0910
Mailing Address - Fax:
Practice Address - Street 1:5290 MILITARY RD STE 8
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1953
Practice Address - Country:US
Practice Address - Phone:716-298-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant