Provider Demographics
NPI:1649723289
Name:BARRACLOUGH, MARON ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARON
Middle Name:ELIZABETH
Last Name:BARRACLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARON
Other - Middle Name:ELIZABETH
Other - Last Name:BRAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14105-1027
Mailing Address - Country:US
Mailing Address - Phone:716-735-7774
Mailing Address - Fax:
Practice Address - Street 1:21 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEPORT
Practice Address - State:NY
Practice Address - Zip Code:14105-1027
Practice Address - Country:US
Practice Address - Phone:716-735-7774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant