Healthcare Provider Details

I. General information

NPI: 1821629510
Provider Name (Legal Business Name): JOSEPH MATHIS QUACKENBUSH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 BANK ST
BATAVIA NY
14020-2250
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-344-7276
  • Fax: 585-344-8190
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024761
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: