Basic Information
Provider Information | |||||||||
NPI: | 1851524847 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROMANIAK | ||||||||
FirstName: | ELYSE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 346 GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 137902580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077298156 | ||||||||
FaxNumber: | 6077292209 | ||||||||
Practice Location | |||||||||
Address1: | 200 FRONT ST | ||||||||
Address2: |   | ||||||||
City: | VESTAL | ||||||||
State: | NY | ||||||||
PostalCode: | 138501559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6076581003 | ||||||||
FaxNumber: | 6076581006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2009 | ||||||||
LastUpdateDate: | 08/25/2015 | ||||||||
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 | PA030624 | DC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 014521 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.