Provider Demographics
NPI:1508856675
Name:TREVISANI, ELAINE MARIE (ANP)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:MARIE
Last Name:TREVISANI
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:ROMANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:110 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6302
Mailing Address - Country:US
Mailing Address - Phone:315-624-7000
Mailing Address - Fax:
Practice Address - Street 1:110 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6302
Practice Address - Country:US
Practice Address - Phone:315-624-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301774-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02642244Medicaid
NY02642244Medicaid