Provider Demographics
NPI:1336669043
Name:SASENBURY, PHILA M
Entity Type:Individual
Prefix:
First Name:PHILA
Middle Name:M
Last Name:SASENBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PHILA
Other - Middle Name:M
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:600 ROE AVE STE 4A
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-271-3780
Practice Address - Fax:607-271-3894
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY604130163W00000X
NY342020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103382724Medicaid
NY04836233Medicaid