Healthcare Provider Details

I. General information

NPI: 1508357724
Provider Name (Legal Business Name): EMILY ELBOGEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18606 UNION TPKE
FRESH MEADOWS NY
11366-1734
US

IV. Provider business mailing address

7374 136TH ST
FLUSHING NY
11367-2827
US

V. Phone/Fax

Practice location:
  • Phone: 718-575-0974
  • Fax:
Mailing address:
  • Phone: 347-415-0930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: