Provider Demographics
NPI:1750464160
Name:STRACK, BETSY L (PA)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:L
Last Name:STRACK
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 1:6763 ERIE RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9670
Mailing Address - Country:US
Mailing Address - Phone:716-947-2222
Mailing Address - Fax:716-947-2223
Practice Address - Street 1:6763 ERIE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9670
Practice Address - Country:US
Practice Address - Phone:716-947-2222
Practice Address - Fax:716-947-2223
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02865832Medicaid