Provider Demographics
NPI:1477506947
Name:ELTAY, IMAN (PA)
Entity Type:Individual
Prefix:
First Name:IMAN
Middle Name:
Last Name:ELTAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:IMAN
Other - Middle Name:
Other - Last Name:GRISCHY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:8350 ARBOR SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-5000
Mailing Address - Country:US
Mailing Address - Phone:513-346-3399
Mailing Address - Fax:
Practice Address - Street 1:8350 ARBOR SQUARE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-5000
Practice Address - Country:US
Practice Address - Phone:513-346-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA890363A00000X
OH50002267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0270943Medicaid
KY7100289930Medicaid
OH0077588Medicaid
Q40042Medicare UPIN
OH0077588Medicaid
ME9313196Medicare PIN