Provider Demographics
NPI:1487678447
Name:GLEASMAN, ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GLEASMAN
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 1:13407 STATE ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13309
Mailing Address - Country:US
Mailing Address - Phone:315-942-3500
Mailing Address - Fax:315-942-3618
Practice Address - Street 1:13407 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13309
Practice Address - Country:US
Practice Address - Phone:315-942-3500
Practice Address - Fax:315-942-3618
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332460363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS75506Medicare UPIN
NYDD0158Medicare PIN
NYDD3833Medicare PIN