Healthcare Provider Details

I. General information

NPI: 1528164464
Provider Name (Legal Business Name): GRACIELA WEST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TITUS PLACE
WALTON NY
13856
US

IV. Provider business mailing address

1 TITUS PLACE
WALTON NY
13856
US

V. Phone/Fax

Practice location:
  • Phone: 607-865-2100
  • Fax: 607-865-7305
Mailing address:
  • Phone: 607-865-2100
  • Fax: 607-865-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004625
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: