Healthcare Provider Details

I. General information

NPI: 1821387937
Provider Name (Legal Business Name): ELIZABETH ANNE WESTENDORF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 MEDFORD AVE
PATCHOGUE NY
11772-1206
US

IV. Provider business mailing address

130 MEDFORD AVE
PATCHOGUE NY
11772-1206
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-5734
  • Fax: 631-758-2568
Mailing address:
  • Phone: 631-475-5734
  • Fax: 631-758-2568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA4050
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number015437-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: