Provider Demographics
NPI:1023624608
Name:AVILA, BERNADETTE
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:153-261-3300
Mailing Address - Fax:
Practice Address - Street 1:49 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1889
Practice Address - Country:US
Practice Address - Phone:315-261-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-19
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant