=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518342484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH L. MATERA PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2015
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 S PORTER ST
-----------------------------------------------------
City | WATKINS GLEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14891-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-535-7873
-----------------------------------------------------
Fax | 607-535-7469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 IVY ST STE 206
-----------------------------------------------------
City | ELMIRA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14905-1627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-271-2050
-----------------------------------------------------
Fax | 607-271-2071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 018756
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------