Provider Demographics
NPI:1740592344
Name:ELLER, ALEXANDER JOSEPH (NURSE PRACTIONER)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JOSEPH
Last Name:ELLER
Suffix:
Gender:M
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6682 STAGE RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6912
Mailing Address - Country:US
Mailing Address - Phone:315-797-6728
Mailing Address - Fax:
Practice Address - Street 1:238 ORISKANY BLVD
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-1540
Practice Address - Country:US
Practice Address - Phone:315-768-7181
Practice Address - Fax:315-768-7182
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY369122163W00000X
NYF401301-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse