Provider Demographics
NPI:1114021805
Name:DEBADTS, EMILY L (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:L
Last Name:DEBADTS
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 1:1250 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1057
Mailing Address - Country:US
Mailing Address - Phone:315-332-2427
Mailing Address - Fax:315-332-2324
Practice Address - Street 1:1250 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1057
Practice Address - Country:US
Practice Address - Phone:315-332-2427
Practice Address - Fax:315-332-2324
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7750884OtherAETNA
NYPA1561Medicare PIN
NYQ75084Medicare UPIN
NY7750884OtherAETNA