Provider Demographics
NPI:1013922723
Name:ELLSWORTH, PRASHULA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:PRASHULA
Middle Name:
Last Name:ELLSWORTH
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 1:6255 SHERIDAN DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4836
Mailing Address - Country:US
Mailing Address - Phone:716-857-8666
Mailing Address - Fax:716-857-8944
Practice Address - Street 1:6333 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5800
Practice Address - Country:US
Practice Address - Phone:716-630-1164
Practice Address - Fax:716-630-2608
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007118-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000570254007OtherHEALTH NOW
NY161000580OtherNOVA
NY00026513001OtherUNIVERA
NY9512316OtherIHA
NYCC3993Medicare PIN
NY00026513001OtherUNIVERA