Provider Demographics
NPI:1790864148
Name:DAMODAR, STEPHANIE T (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:T
Last Name:DAMODAR
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 1:565 ABBOTT RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-2039
Mailing Address - Country:US
Mailing Address - Phone:716-725-1654
Mailing Address - Fax:
Practice Address - Street 1:565 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-2039
Practice Address - Country:US
Practice Address - Phone:716-725-1654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003134363A00000X
NY010938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1354Medicare ID - Type Unspecified
NYQ67704Medicare UPIN