Provider Demographics
NPI:1508063140
Name:MIKUSZEWSKI, ELIZABETH MARIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:MIKUSZEWSKI
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 PEARL ST
Mailing Address - Street 2:REAR APT
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-3732
Mailing Address - Country:US
Mailing Address - Phone:716-969-4087
Mailing Address - Fax:
Practice Address - Street 1:196 NORTH ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1651
Practice Address - Country:US
Practice Address - Phone:315-787-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant