Provider Demographics
NPI:1194019703
Name:HODGES, EILEEN TERESA (PA)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:TERESA
Last Name:HODGES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:EILEEN
Other - Middle Name:TERESA
Other - Last Name:STOCUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5905 CREEKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9735
Mailing Address - Country:US
Mailing Address - Phone:716-480-1918
Mailing Address - Fax:
Practice Address - Street 1:1540 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3647
Practice Address - Country:US
Practice Address - Phone:716-568-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014834363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical