Healthcare Provider Details

I. General information

NPI: 1073996930
Provider Name (Legal Business Name): MARIAH K. RITTWAGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAH K. EASTON PA-C

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 07/03/2023
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 LODER ST STE A
HORNELL NY
14843-1950
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 607-324-5404
  • Fax: 607-324-5463
Mailing address:
  • Phone: 607-324-5404
  • Fax: 607-324-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number21892
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number021892
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: