Basic Information
| Provider Information | |||||||||
| NPI: | 1013922723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLSWORTH | ||||||||
| FirstName: | PRASHULA | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6255 SHERIDAN DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142214836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578666 | ||||||||
| FaxNumber: | 7168578944 | ||||||||
| Practice Location | |||||||||
| Address1: | 6333 MAIN ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301164 | ||||||||
| FaxNumber: | 7166302608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 007118-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000570254007 | 01 | NY | HEALTH NOW | OTHER | 161000580 | 01 | NY | NOVA | OTHER | 00026513001 | 01 | NY | UNIVERA | OTHER | 9512316 | 01 | NY | IHA | OTHER |