Provider Demographics
NPI:1104120575
Name:DIENSTAG, BILL DAVID (PAC)
Entity type:Individual
Prefix:MR
First Name:BILL
Middle Name:DAVID
Last Name:DIENSTAG
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:600 IVY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1627
Practice Address - Country:US
Practice Address - Phone:607-737-7780
Practice Address - Fax:607-737-7788
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006144OtherNY STATE LICENSE
NY04297325Medicaid
NY04297325Medicaid
NY04297325Medicaid