Provider Demographics
NPI:1962921023
Name:MCTAVISH, ELANA CHLOE (PA-C)
Entity type:Individual
Prefix:
First Name:ELANA
Middle Name:CHLOE
Last Name:MCTAVISH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELANA
Other - Middle Name:CHLOE
Other - Last Name:O'HARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:122 MEADOW HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-1253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2870
Practice Address - Country:US
Practice Address - Phone:203-384-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22237083363AS0400X
CO6036363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical