Provider Demographics
NPI:1679981401
Name:SANDERS, ELIZABETH ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:LUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:185 OLD COUNTRY RD
Mailing Address - Street 2:STE 2
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2121
Mailing Address - Country:US
Mailing Address - Phone:631-298-4479
Mailing Address - Fax:631-591-3047
Practice Address - Street 1:496 COUNTY ROAD 111
Practice Address - Street 2:BUILDING B
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949
Practice Address - Country:US
Practice Address - Phone:631-405-3200
Practice Address - Fax:631-395-6010
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2015-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017746-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical