Provider Demographics
NPI:1720710536
Name:ELMENDORF, PHOEBE SUSAN (PA-C)
Entity type:Individual
Prefix:
First Name:PHOEBE
Middle Name:SUSAN
Last Name:ELMENDORF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-3101
Mailing Address - Country:US
Mailing Address - Phone:845-337-6380
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3815
Practice Address - Country:US
Practice Address - Phone:203-852-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5759363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant