Provider Demographics
NPI:1780662965
Name:SHABEN, ELAINE J (NP)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:J
Last Name:SHABEN
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 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6564
Mailing Address - Fax:315-298-7488
Practice Address - Street 1:61 DELANO ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-1400
Practice Address - Country:US
Practice Address - Phone:315-298-6564
Practice Address - Fax:315-298-7488
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334673363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00334673Medicaid
NY00307662Medicaid
331880OtherFQHC NUMBER