Healthcare Provider Details

I. General information

NPI: 1063989200
Provider Name (Legal Business Name): MATTHEW JOSPEH DALEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3011
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-2000
  • Fax: 585-922-2951
Mailing address:
  • Phone: 585-922-2000
  • Fax: 585-922-2951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number025084
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: