Provider Demographics
NPI:1972085397
Name:WATT, ELENA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:MARIE
Last Name:WATT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FOREST CREEK LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072
Mailing Address - Country:US
Mailing Address - Phone:716-868-7465
Mailing Address - Fax:
Practice Address - Street 1:263 FOREST CREEK LN
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-3507
Practice Address - Country:US
Practice Address - Phone:716-868-7465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-01
Last Update Date:2018-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant