Basic Information
| Provider Information | |||||||||
| NPI: | 1386835783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLEZEAU | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8750 TRANSIT RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | EAST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140512610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166361470 | ||||||||
| FaxNumber: | 7166361423 | ||||||||
| Practice Location | |||||||||
| Address1: | 8750 TRANSIT RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | EAST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140512610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166361470 | ||||||||
| FaxNumber: | 7166361423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 08/10/2012 | ||||||||
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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 | 363AS0400X | 011994 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 011994 | 01 | NY | LICENSE | OTHER |