Basic Information
Provider Information | |||||||||
NPI: | 1679981401 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDERS | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUM | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 185 OLD COUNTRY RD | ||||||||
Address2: | STE 2 | ||||||||
City: | RIVERHEAD | ||||||||
State: | NY | ||||||||
PostalCode: | 119012121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312984479 | ||||||||
FaxNumber: | 6315913047 | ||||||||
Practice Location | |||||||||
Address1: | 496 COUNTY ROAD 111 | ||||||||
Address2: | BUILDING B | ||||||||
City: | MANORVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 11949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6314053200 | ||||||||
FaxNumber: | 6313956010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2014 | ||||||||
LastUpdateDate: | 02/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 017746-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.