Provider Demographics
NPI:1477644508
Name:DAETSCH, EILEEN (NP)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:DAETSCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3980 SHERIDAN DR
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1727
Mailing Address - Country:US
Mailing Address - Phone:716-882-6544
Mailing Address - Fax:716-882-6833
Practice Address - Street 1:3980 SHERIDAN DR
Practice Address - Street 2:6TH FLOOR
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1727
Practice Address - Country:US
Practice Address - Phone:716-882-6544
Practice Address - Fax:716-882-6833
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300156-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9512106OtherINDEPENDENT HEALTH
NY00026511101OtherEXCELLUS UNIVERA
NY01816059Medicaid
NY005603231OtherHEALTH NOW
NY005603231OtherHEALTH NOW
NYS53570Medicare UPIN
NY01816059Medicaid