Provider Demographics
NPI:1285906768
Name:UPHAM, ELIZABETH BROOKS (ANP-BC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROOKS
Last Name:UPHAM
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:E.
Other - Middle Name:BROOKS
Other - Last Name:UPHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP, RN
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:16707 29TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1501
Practice Address - Country:US
Practice Address - Phone:917-650-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305957-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE48847Medicare UPIN
NYG23340Medicare UPIN