Healthcare Provider Details

I. General information

NPI: 1467093880
Provider Name (Legal Business Name): ANDREW D MANGIACAPRE AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 07/03/2023
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 SOUTH AVE
ROCHESTER NY
14620-2733
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 655
ROCHESTER NY
14642-1459
US

V. Phone/Fax

Practice location:
  • Phone: 585-473-2200
  • Fax:
Mailing address:
  • Phone: 585-273-4398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number435532
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number309500
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number309500
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: