Provider Demographics
NPI:1073730982
Name:KUPERSHMIDT, ELENA (PA)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:KUPERSHMIDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 KINGS HWY APT B6
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1629
Mailing Address - Country:US
Mailing Address - Phone:718-338-9274
Mailing Address - Fax:
Practice Address - Street 1:2425 KINGS HWY APT B6
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1629
Practice Address - Country:US
Practice Address - Phone:718-338-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010243363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical