Healthcare Provider Details

I. General information

NPI: 1033486899
Provider Name (Legal Business Name): PHILIPP EWERT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 PRE EMPTION RD
GENEVA NY
14456-2069
US

IV. Provider business mailing address

789 PRE EMPTION RD
GENEVA NY
14456-2069
US

V. Phone/Fax

Practice location:
  • Phone: 315-789-0993
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: