Healthcare Provider Details

I. General information

NPI: 1124431655
Provider Name (Legal Business Name): ELIZABETH ONTIVEROS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 CENTRAL AVE
FAR ROCKAWAY NY
11691-4002
US

IV. Provider business mailing address

17002 GLENEAGLE DR S STE 101
CONROE TX
77385-4614
US

V. Phone/Fax

Practice location:
  • Phone: 718-831-2755
  • Fax:
Mailing address:
  • Phone: 832-447-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09672
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032314
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: