Healthcare Provider Details

I. General information

NPI: 1154115418
Provider Name (Legal Business Name): ETHAN CONNOR HRYHORENKO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE BLDG 3
ROCHESTER NY
14621-3095
US

IV. Provider business mailing address

45 FRASER DR
HILTON NY
14468-1348
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-4000
  • Fax:
Mailing address:
  • Phone: 585-267-0025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036722
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: