Healthcare Provider Details

I. General information

NPI: 1083220677
Provider Name (Legal Business Name): ELLEN MCSTRAVICK AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER ST FL 9
BUFFALO NY
14215-3021
US

IV. Provider business mailing address

163 MERRYMONT RD
CHEEKTOWAGA NY
14225-1503
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-3198
  • Fax:
Mailing address:
  • Phone: 716-319-0508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number309652
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: