Provider Demographics
NPI:1528164464
Name:WEST, GRACIELA (PA)
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TITUS PLACE
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856
Mailing Address - Country:US
Mailing Address - Phone:607-865-2100
Mailing Address - Fax:607-865-7305
Practice Address - Street 1:1 TITUS PLACE
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856
Practice Address - Country:US
Practice Address - Phone:607-865-2100
Practice Address - Fax:607-865-7305
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant